- Email: [email protected]
Factors influencing the outcome of treatment in patients referred to a temporomandibular joint clinic
HART
23.
24. 25.
Coye RB: A study of the variability of setting a fully adjustable gnathologic articulator to a pantographic tracing. J PROSTHET DENT 37:460, 1977. Winstanley RB: Observations on the use of the Denar pantograph and articulator. J PROSTHET DENT 38:660, 1977. Jaarda >IJ, Clayton JA: Measurement of cusp height and ridge and groove direction, using an electrical transducer. Part I: Instrumentation. J PROSTIIET DENT 39:678, 1978.
26.
Riis D, Giddon DB: Interdental discrimmation dill’erences. J PROSTHET DENT 24~324, 1970.
AND
SAKAMURA
of small thickness
Ke,b,rml w/Ut?,I.\ to: DR. JERRY KENNIWN HART UNIVERSITY OF MISS~UKI SCHOOL OF DENTISTRY, RM. 3- 104 KANSAS CITY, MO 64108
Factors influencing the outcome of treatment in patients referred to a temporomandibular joint clinic Anita
Wedel, L.D.S.,*
University
of Giiteborg,
and Gunnar
E. Carlsson,
Faculty of Odontology,
Giiteborg,
L.D.S., Odont.Dr.** Sweden
Ah e proposed multicausal etiology of temporomandibular joint (TMJ) disorders may explain the diverse treatment methods and their reported successes.‘-*While few carefully controlled comparative studies of treatment efficacy are available, a wide variety of specific and adjunctive therapies have been suggested, for example, biofeedback, hypnosis and other psychologic methods, acupuncture and electrical physical therapy, myofunctional therapy, and special techniques for TMJ surgery. + s,‘-I3 A multiprofessional approach in the management of patients with TMJ disorders has also been recommended.5~‘4~‘5While this might be necessary for a small group of patients, it is well documented that most TM J disorders can be successfully treated with counseling and simple dental methods.“,‘” It is difficult to perform comparative, studies of different treatment methods, and a wide disparity of thinking still exists in this field;9~‘0~“2” therefore, it is desirable to analyze the outcome of therapy in other ways. We chose to retrospectively study the number of visits, length of treatment period, and evaluation of clinical status at end of treatment in a relatively large group of patients who had been referred for treatment of functional disturbances of the masticatory system.
MATERIAL
AND
METHODS
Three hundred-fifty consecutive patients with functional disturbances of the masticatory system attending Supported by grants from Stiftelsen Handlanden Hjalmar Svenssons Forskningsfond, and the American Equilibration Society. *lIssistant Professor, Department of Stomatognathic Physiology. **Professor .~nd Chairman, Department of Stomatognathic Physiology. 420
the Department of Stomatognathic Physiology, University of Goteborg, were chosen for this study. The patients answered a self-administered questionnaire at their first visit. The design of the questionnaire study and results of analyses of the answers ,to the questions were reported elsewhere.“,‘(’ The patients were examined and treated at the clinic according to routine clinical procedures.‘6 Two and one-half years after the first visit, the records of the patients were examined for clinical findings, diagnoses, and observations related to treatment. A description of the main results of these observations were presented previously.2’ A series of variables were selected from the questionnaire and the patient records (Table I) for further statistical analyses with special respect to number of visits, length of treatment period, and evaluation of the patients’ signs and symptoms at the last clinic visit.
Statistical
methods
The variables listed in Table I were correlated one by one by means of Spearman’s nonparametric rank correlation test22 with each of the following three variables: (1) number of visits, (2) length of treatment in months, and (3) final evaluation of the signs and symptoms. Stepwise multiple regression analysis was then performed with the variables in Table I as independent variables and each of the three above-mentioned parameters as dependent variables. Subgroups of patients were also selected in different ways for comparison of the treatment results.
RESULTS The distribution of the number of visits and the length of treatment are shown in Figs. 1 and 2. There is a wide SEPTEMBER
1985
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NUMBER
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FACTORS
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TMJ
% of patients
TREATMENT
OUTCOME
15 .
visits
Fig. 1. Distribution
Table I. Variables General
used in correlation
of patients
and regression
included
in Helkimo’s
index ” (0 = no; 1 = mild;
of visits.
analyses
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Evaluation of initial symptoms (1 = no or slight; 5 = very severe) Demand for treatment of initial symptoms (1 = immediate; 4 = can wait 6 months) Frequency of symptoms (1 = every day; 4 = a couple of times a year) Ejfect of symptoms on patient (0 = no; 1 = yes) Sick leave Disturb sleep Disturb job Worry much Have no medication Symptoms do not bother much Clinical recordings at first viszt Clinical dysfunction index” (0 = no dysfunction; 3 = severe dysfunction) Impaired TMJ function* Tenderness on palpation of TMJ” Tenderness on muscle palpation* Pain on mandibular movement* Limitation of mandibular mobility* Maximal mouth opening (in mm) RP-IP distance (in mm) Number of teeth Number of occluding teeth Occlusal interferences in RP Occlusal interferences in laterotrusion Occlusal interference index (addition of the above interferences) Occlusal index)’ (0 = no; 1 = mild; 2 = severe disturbance)
and 5 = severe sign)
but the median values are relatively low at four visits and 3 months, respectively. The results of the evaluation in five categories of the patients’ symptoms at termination of the treatment period are presented in variation,
THE
to number
variables
Age Sex General state of health (1 = good; 3 = poor) Reported general disease Nervous or psychic problems (0 = no; 3 = yes, treatment now) Education (1 = elementary school; 5 = university degree) Family situation (1 = good; 4 = very troublesome) Social situation (0 = “normal”; 1 = poor) Previous treatment for actual signs and symptoms (1 = no; 5 = yes, at many therapists) Reported symptoms at first visit (0 = no; 1 = yes) Pain in face and jaws Pain on movement of mandible Difficulties in opening the mouth wide Chewing difficulties Locking or dislocation of mandible Clicking of TMJ Crepitatlon of TMJ Feeling of fatigue in jaws or cheeks Headache Dizziness (vertigo) Earbuzzing (tinnitus), impaired hearing Swallowing difficulties, globus in the throat Tongue pain Clenching of teeth Grinding of teeth Extensive wear of teeth Number of reported symptoms Duration of initial symptoms (1 = less than 1 month; 6 = more than 5 years) *Signs
according
Table II. Three-fourths of the patients had a reduction of the severity of signs and symptoms at the final evaluation, but 3% had an impairment of their signs and symptoms. 421
WEDEL
AND
CARLSSOh
%
of patients
25
2
4
Fig. 2. Distribution
6
8
10
of patients
12
according
Table II. Evaluation
of signs and symptoms at discharge (percent distribution in 228 women and 110 men patients)* Evaluation 1. 2. 3. 4. 5.
No signs or symptoms Marked improvement Certain improvement No certain change Deterioration
Women
Men
Total
16 34 22 25 4
18 32 26 23 0
17 33 23 24 3
*In 12 of 350 patients no certain information was aGlable.
A number of variables (Table I) were correlated one by one to number of visits, length of treatment, and evaluation of signs and symptoms at last visit (Table III). Sixteen single variables were significantly (p < .Ol) correlated with number of visits. Seven variables, with tenderness on muscle palpation at first visit as the most important, were found to influence the number of visits significantly @ < .Ol) in the regression analysis performed in the 170 patients with no missing data in all the variables of Table I (Table IV). These seven variables explained about 28% (R* = 0.28) of the variance of the dependent variable. Three of the seven variables also had a significant influence on the length of treatment, with muscle tenderness as the most important. The eight variables that were significant according to the regression analysis could explain about 27% of the variance (Table V). No single variable was significantly (p < .Ol) correlated with evaluation of the treatment result according to the analysis in all patients (Table III). A multiple regression analysis performed in the 170 patients with422
14
16
18
to length
20
22
24
of treatment
26
period
28
Months
(in months).
out missing data for the variables in Table I showed that four of the independent variables had a significant influence on “treatment result” with a report that the initial symptoms disturbed the patient’s work was the most important (Table VI). The explanatory value of these four variables was about 15% (R* = 0.15). Division of the patients into subgroups with respect to symptoms and the diagnoses “mandibular dysfunction” and “TMJ disease” showed only small differences for means and medians of number of visits, length of treatment, and evaluation at termination of treatment (Table VII). The median values for initial evaluation of severity of symptoms D, and Oi were also similar. Patients with good occlusal conditions (0; = 0) and mild dysfunction (D, = 0 or l), those with a diagnosis of mainly TMJ clicking, and those with a diagnosis not referrable to the masticatory system averaged fewer visits and shorter treatment time than the means for all patients. The individual variation was great, however, in all subgroups. The records of the nine patients who were classified as worse at the final visit were scrutinized again. All nine were women with an age range of 21 to 71 years. The number of visits for these patients varied from two to nine. Two had increasing facial pain and headache that were probably ndt or only partially related to the masticatory system. Both were eventualiy referred for neurologic examination and treatment. In -one patiennt, the aggravating pain was finally diagnosed to be of pulpal origin in a fixed partia1 denture abutment2 Two patients had first been successfully treated but had experienced recurrences at the time of the review. The remaining four patients had obvious Ructiation of pain and dysfu6ction: relatively mild sympto& at first visit without need of treatment and later intensified signs and SEPTEMBER
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OUTCOME
Table III. Significant correlations between independent to Spearman rank correlation test (p < .Ol)
variables
and dependent
Dependent Independent
variables
No.
Social situation Tooth clenching Crepitatlon of TMJ Headache Dizziness (vertigo) Ear-buzzing, impaired hearing Tongue pain Number of reported symptoms Duration of initial symptoms Evaluation of initial symptoms Demand for treatment Sick leave because of symptoms Symptoms do not bother much Dysfunction index Tenderness on muscle palpation Limitation of mandibular mobility Occlusal interference index + = I’ositivc correlation correlation ill j> 5 .OOl.
aI 0.001
,/I 5 .Ol;
of visits
Length
NS + NS NS NS NS NS ++ NS + -
+ -
NS -
++ ++ ++
negative
Evaluation
correlation
+ NS
symptoms requiring treatment, including prosthetic rehabilitation in three. A new analysis of the records of the 24 patients who had more than 10 (range 11 to 25) visits during the treatment period was made. They comprised 18 women and six men, 19 to 68 years of age. The main explanation for the great number of visits was the type of treatment provided and the development of signs and symptoms. In seven patients, prosthetic rehabilitation requiring many visits was performed. Eight patients had fluctuating or recurrent signs and symptoms that called for repeated treatment periods, while another nine patients experienced no improvement initially and therefore had new treatment attempts. In one, the aggravating TMJ pain finally led to TM J meniscectomy. The evaluation of signs and symptoms at the last visit averaged no worse for this group than for the others.
at 0.001
/J 5 .Ol ; ++
at last
visit
NS NS NS his NS NS NS N5 NS NS NS NS NS NS NS NS NS
++ ++ +
-=
variables
of treatment
+ NS + + + + + ++ + ++
variables according
= posirive
correlalion
al /I 15 00 I; --
= Iwgaribc,
Table IV. Independent variables to explain variation of dependent variable, number of visits, according to multiple regression analysis (170 patients)*
Independent
variable
Tenderness on palpation Occlusal interference index Evaluation of initial symptoms Grinding of teeth Symptoms give much worry Occlusal index Number of teeth *Only variables tlt2 = 0.2x.
Type of relation + + + + + +
Significance regression coefficientt (p value)
of
<.OOOl <.OOOl <.0004 <.0026 <.0037 <.0037 <.0049
with ,/I < .Ol are listed.
DISCUSSION This study demonstrated a great variation in response to treatment as indicated by number of visits, length of treatment period, and evaluation of the patients’ signs and symptoms of mandibular dysfunction at the last visit. Our selection of a large group of patients for analysis enabled us to include both “simple” and “difficult” patients. All evaluations of the records were made by the same examiner, who tried to use only clear statements according to preset criteria. An example of this is the data in Table II; if any uncertainty existed between two THE
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DENTISTRY
levels the lower one was always chosen. An attempt will be made in the future to estimate the uncertainty of the method when a group of these patients will be recalled to the clinic. In the follow-up studies of patients at the same clinic, the methodologic problems encountered have been reported. 23-21Patients’ recollection of original symptoms after 7 years was usually in agreement with notes in the patients’ records.24In a neurologic study of chronic-pain patients, the doctor’s global rating of the treatment effect was similar to patients’ self-rating.26 Such results might 423
WEDEI.
Table V. Independent variation of dependent treatment*
Independent
variable
Tenderness on muscle palpation Ear-nose-throat disease Grinding of teeth *ae
Evaluation of initial symptoms Heart or blood disease Limitation of mandibular mobility General state of health
variables to explain variable, length of
Type of relation
+ + +
Significance regression coeficientt (p value)
Table VI. Independent variation of dependent of signs and symptoms ~-___
<.OOOl < 0001 <.OOOl
+ -
<.0032 <.0044 <.0048
+ +
<.0068 < 0084
be taken as support for the method of evaluation used in this study, although the problems of clinical judgment is well known.27 However, the inclusion of specified psychologic and physiologic measures did not solve all methodologic problems in process and outcome studies of patients with dental fear. 2XTherefore, simple clinical evaluation, as used here in a systematized way, seems justified. The number of visits and the length of treatment period are closely correlated, but they differ in relation to other variables (Table III). The number of visits is correlated to more variables and more strongly to those which indicate severity of initial symptoms. The number of visits tends to imply need and demand of more specific treatment measures than the length of treatment period, which is also influenced by waiting periods in more chronic patients. Tenderness on muscle palpation at the first visit had the strongest influence and explained most of the variation of both these dependent variables. Several studies showed that muscle tenderness is the factor that best explains the severity of subjective and clinical dysfunction both in clinical and epidemiologic studies.3,ia29 The present results indicate that muscle tenderness on palpation at the first visit is also of equal importance to the number of visits and length of the treatment period, probably because these factors are influenced by the severity of the initial signs and symptoms. Dental and occlusal factors are correlated to the outcome of treatment only to a small degree in this patient series. This observation corroborates findings reported in other studies. “. 3o An addition index of the types of interference included in the occlusal indexj’ was
424
CARLSSON
variables to explain variable, evaluation at last visit*
of
Independent
AND
Type of relation
variable
Symptoms disturb work Heart or blood disease Maximal mouth opening Pain on movement of mandible
Significance regression coefficient* (p value)
-t
of
<.0004 <.0035 i.0044 <.(I064
--
positively correlated to number of visits; this factor was also of significant influence in the regression analysis (Tables III and IV). On the other hand, the occlusal index was negatively related and number of teeth positively related to the dependent variable (Table IV), which means that the more teeth a patient had, the more visits he made to the clinic. The evaluation of signs and symptoms at last visit was not significantly (la > .Ol) correlated to any of the variables in Table I when all patients were analyzed. In the regression analysis in about half the patients, the variables with, a significant influence had a low explanatory value (Table VI). Thus, the initial severity of dysfunction had no significant influence on the final evaluation after treatment. A possible explanation is that it is difficult to prognosticate the outcome of treatment by means of initial signs and symptoms. On the other hand, it is well acknowledged that both short- and long-term effects of simple treatment is favorable in most patients.” 23,‘4 Information of an usually good prognosis should be conveyed to the patients on initial counseling as positive assurance that they can be helped. The similarity of average treatment results in various subgroups (Table VII) and wide individual variations indicate the heterogeneity of the clientele and the impossible task to find a “typical” TM J disorder patient. It is interesting to note that the small group of patients (15 of 350) who considered locking or dislocation of the mandible (indicating a clinical diagnosis of disk displacement) to be the most troublesome symptom did not deviate as to outcome of treatment from those who had the diagnosis “mandibular dysfunction.” A similar observation of favorable prognosis for locking of the mandible was made in a 7-year follow-up.24 This indicates that it is not necessary to overdramatize this symptom. Only one of the 350 patients was referred for TM J surgery, which is in agreement with the restrictive~ attitude toward this treatment modality at the clinic.‘”
SEPTEMBER
1985
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NUMBER
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FACTORS
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Table VII. Means (jz) and medians (M) for number of visits, length of treatment (in months), and final evaluation of signs and symptoms; and medians of patients’ evaluation of severity of initial
symptoms,
clinical dysfunction
(Di), and occlusal index (0,)’ Number of visits
Patient
grow
-
Length of treatment
Final evaluationt
Initial symptoms M
Di
0;
M
M
No.
%
M
R
M
Iz
M
212 108 56 156
5.5 6.1 4.8 5.6
5 5 4 5
6.5 7.3 4.9 6.4
4 4 2.5 4
2.6 2.7 2.8 2.8
3 2.5 3 3
2 2 2 2
1 1 1 2
30
3.9
3.5
4.3
2
2.8
3
1
1
41 124
6.1 3.9
4 3.5
6.5 4.3
3 2
2.9 2.8
3 3
2 1
2 1
180 32 25 16
5.7 5.8 2.9 1.7
5 5 2 1
6.1 6.7 2.6 2.1
4 4 1 1
2.5 2.6 2.9 2.8
2 3 3 3
2 2 1 1
1 1 1 1.5
171
5.5
5
6.1
4
1.7
2
2
1
9 57
7.9 3.1
5 3
11.9 2.5
5 1
5.0 3.6
5 4
3 2
2 1
15 44 8
5.7 5.7 6.3
5 5 5
4.3 6.5 6.9
3 4.5 3
2.6 2.8 2.4
2 2.5 2
2 2 2.5
1 1 1.5
Sytrlytorns
Typical pain-dysfunction symptoms Peripheral, bizarre symptoms Headache as main symptom Duration of symptoms > 1 year C/inrcai
filldlrlg
Natural dentition without disturbances (0, = 0) Denture wearers Mild clinical dysfunction (D,=OorI) Dn~,ylll”lS Mandibular dysfunction TMJ disease Mainly clicking of TMJ Not referrable to masticatory system Outco~trr
of trcattnmt
Symptom free or marked improvement (scale value 1 or 2) Worse (scale value 5) Discontinuance of treatment; lack of cooperation Most froublesotne symptom Locking or dislocation of mandible Headache Ear buzzing (tinnitus)
SUMMARY review was performed in 350 consecutive patients referred for functional disturbances of the masticatory system. Two and one-half years after the first visit, the records of all patients were examined for clinical findings, diagnosis, and observations related to treatment. Number of visits, length of the treatment period, and evaluation of signs and symptoms at last visit (factors which showed a wide variation) were analyzed for correlation with signs and symptoms at first visit and some background factors. A total of 50 variables were considered. The number of visits and length of treatment period were primarily correlated with variables that indicated the severity of signs and symptoms at the first visit. Multiple regression analysis showed that tenderness on muscle palpation at first visit was the most important of the independent variables. About onefourth of the variance of number of visits and length of A retrospective
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
treatment could be explained (R’ = 0.28 and 0.27, respectively), while the corresponding value for the variance of the evaluation at last visit was 15% (R’ = 0.15). The results tend to emphasize the heterogeneity of patients with functional disturbances of the masticatory system and the difficulty of prognosticating the outcome of treatment in such patients, even when attempts are made to divide them into subgroups. REFERENCES I.
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1985
VOLUME
54
NUMBER
3
23.
24. 25.
Coye RB: A study of the variability of setting a fully adjustable gnathologic articulator to a pantographic tracing. J PROSTHET DENT 37:460, 1977. Winstanley RB: Observations on the use of the Denar pantograph and articulator. J PROSTHET DENT 38:660, 1977. Jaarda >IJ, Clayton JA: Measurement of cusp height and ridge and groove direction, using an electrical transducer. Part I: Instrumentation. J PROSTIIET DENT 39:678, 1978.
26.
Riis D, Giddon DB: Interdental discrimmation dill’erences. J PROSTHET DENT 24~324, 1970.
AND
SAKAMURA
of small thickness
Ke,b,rml w/Ut?,I.\ to: DR. JERRY KENNIWN HART UNIVERSITY OF MISS~UKI SCHOOL OF DENTISTRY, RM. 3- 104 KANSAS CITY, MO 64108
Factors influencing the outcome of treatment in patients referred to a temporomandibular joint clinic Anita
Wedel, L.D.S.,*
University
of Giiteborg,
and Gunnar
E. Carlsson,
Faculty of Odontology,
Giiteborg,
L.D.S., Odont.Dr.** Sweden
Ah e proposed multicausal etiology of temporomandibular joint (TMJ) disorders may explain the diverse treatment methods and their reported successes.‘-*While few carefully controlled comparative studies of treatment efficacy are available, a wide variety of specific and adjunctive therapies have been suggested, for example, biofeedback, hypnosis and other psychologic methods, acupuncture and electrical physical therapy, myofunctional therapy, and special techniques for TMJ surgery. + s,‘-I3 A multiprofessional approach in the management of patients with TMJ disorders has also been recommended.5~‘4~‘5While this might be necessary for a small group of patients, it is well documented that most TM J disorders can be successfully treated with counseling and simple dental methods.“,‘” It is difficult to perform comparative, studies of different treatment methods, and a wide disparity of thinking still exists in this field;9~‘0~“2” therefore, it is desirable to analyze the outcome of therapy in other ways. We chose to retrospectively study the number of visits, length of treatment period, and evaluation of clinical status at end of treatment in a relatively large group of patients who had been referred for treatment of functional disturbances of the masticatory system.
MATERIAL
AND
METHODS
Three hundred-fifty consecutive patients with functional disturbances of the masticatory system attending Supported by grants from Stiftelsen Handlanden Hjalmar Svenssons Forskningsfond, and the American Equilibration Society. *lIssistant Professor, Department of Stomatognathic Physiology. **Professor .~nd Chairman, Department of Stomatognathic Physiology. 420
the Department of Stomatognathic Physiology, University of Goteborg, were chosen for this study. The patients answered a self-administered questionnaire at their first visit. The design of the questionnaire study and results of analyses of the answers ,to the questions were reported elsewhere.“,‘(’ The patients were examined and treated at the clinic according to routine clinical procedures.‘6 Two and one-half years after the first visit, the records of the patients were examined for clinical findings, diagnoses, and observations related to treatment. A description of the main results of these observations were presented previously.2’ A series of variables were selected from the questionnaire and the patient records (Table I) for further statistical analyses with special respect to number of visits, length of treatment period, and evaluation of the patients’ signs and symptoms at the last clinic visit.
Statistical
methods
The variables listed in Table I were correlated one by one by means of Spearman’s nonparametric rank correlation test22 with each of the following three variables: (1) number of visits, (2) length of treatment in months, and (3) final evaluation of the signs and symptoms. Stepwise multiple regression analysis was then performed with the variables in Table I as independent variables and each of the three above-mentioned parameters as dependent variables. Subgroups of patients were also selected in different ways for comparison of the treatment results.
RESULTS The distribution of the number of visits and the length of treatment are shown in Figs. 1 and 2. There is a wide SEPTEMBER
1985
VOLUME
54
NUMBER
3
FACTORS
INFLUENCING
TMJ
% of patients
TREATMENT
OUTCOME
15 .
visits
Fig. 1. Distribution
Table I. Variables General
used in correlation
of patients
and regression
included
in Helkimo’s
index ” (0 = no; 1 = mild;
of visits.
analyses
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OF PROSTHETIC
DENTISTRY
Evaluation of initial symptoms (1 = no or slight; 5 = very severe) Demand for treatment of initial symptoms (1 = immediate; 4 = can wait 6 months) Frequency of symptoms (1 = every day; 4 = a couple of times a year) Ejfect of symptoms on patient (0 = no; 1 = yes) Sick leave Disturb sleep Disturb job Worry much Have no medication Symptoms do not bother much Clinical recordings at first viszt Clinical dysfunction index” (0 = no dysfunction; 3 = severe dysfunction) Impaired TMJ function* Tenderness on palpation of TMJ” Tenderness on muscle palpation* Pain on mandibular movement* Limitation of mandibular mobility* Maximal mouth opening (in mm) RP-IP distance (in mm) Number of teeth Number of occluding teeth Occlusal interferences in RP Occlusal interferences in laterotrusion Occlusal interference index (addition of the above interferences) Occlusal index)’ (0 = no; 1 = mild; 2 = severe disturbance)
and 5 = severe sign)
but the median values are relatively low at four visits and 3 months, respectively. The results of the evaluation in five categories of the patients’ symptoms at termination of the treatment period are presented in variation,
THE
to number
variables
Age Sex General state of health (1 = good; 3 = poor) Reported general disease Nervous or psychic problems (0 = no; 3 = yes, treatment now) Education (1 = elementary school; 5 = university degree) Family situation (1 = good; 4 = very troublesome) Social situation (0 = “normal”; 1 = poor) Previous treatment for actual signs and symptoms (1 = no; 5 = yes, at many therapists) Reported symptoms at first visit (0 = no; 1 = yes) Pain in face and jaws Pain on movement of mandible Difficulties in opening the mouth wide Chewing difficulties Locking or dislocation of mandible Clicking of TMJ Crepitatlon of TMJ Feeling of fatigue in jaws or cheeks Headache Dizziness (vertigo) Earbuzzing (tinnitus), impaired hearing Swallowing difficulties, globus in the throat Tongue pain Clenching of teeth Grinding of teeth Extensive wear of teeth Number of reported symptoms Duration of initial symptoms (1 = less than 1 month; 6 = more than 5 years) *Signs
according
Table II. Three-fourths of the patients had a reduction of the severity of signs and symptoms at the final evaluation, but 3% had an impairment of their signs and symptoms. 421
WEDEL
AND
CARLSSOh
%
of patients
25
2
4
Fig. 2. Distribution
6
8
10
of patients
12
according
Table II. Evaluation
of signs and symptoms at discharge (percent distribution in 228 women and 110 men patients)* Evaluation 1. 2. 3. 4. 5.
No signs or symptoms Marked improvement Certain improvement No certain change Deterioration
Women
Men
Total
16 34 22 25 4
18 32 26 23 0
17 33 23 24 3
*In 12 of 350 patients no certain information was aGlable.
A number of variables (Table I) were correlated one by one to number of visits, length of treatment, and evaluation of signs and symptoms at last visit (Table III). Sixteen single variables were significantly (p < .Ol) correlated with number of visits. Seven variables, with tenderness on muscle palpation at first visit as the most important, were found to influence the number of visits significantly @ < .Ol) in the regression analysis performed in the 170 patients with no missing data in all the variables of Table I (Table IV). These seven variables explained about 28% (R* = 0.28) of the variance of the dependent variable. Three of the seven variables also had a significant influence on the length of treatment, with muscle tenderness as the most important. The eight variables that were significant according to the regression analysis could explain about 27% of the variance (Table V). No single variable was significantly (p < .Ol) correlated with evaluation of the treatment result according to the analysis in all patients (Table III). A multiple regression analysis performed in the 170 patients with422
14
16
18
to length
20
22
24
of treatment
26
period
28
Months
(in months).
out missing data for the variables in Table I showed that four of the independent variables had a significant influence on “treatment result” with a report that the initial symptoms disturbed the patient’s work was the most important (Table VI). The explanatory value of these four variables was about 15% (R* = 0.15). Division of the patients into subgroups with respect to symptoms and the diagnoses “mandibular dysfunction” and “TMJ disease” showed only small differences for means and medians of number of visits, length of treatment, and evaluation at termination of treatment (Table VII). The median values for initial evaluation of severity of symptoms D, and Oi were also similar. Patients with good occlusal conditions (0; = 0) and mild dysfunction (D, = 0 or l), those with a diagnosis of mainly TMJ clicking, and those with a diagnosis not referrable to the masticatory system averaged fewer visits and shorter treatment time than the means for all patients. The individual variation was great, however, in all subgroups. The records of the nine patients who were classified as worse at the final visit were scrutinized again. All nine were women with an age range of 21 to 71 years. The number of visits for these patients varied from two to nine. Two had increasing facial pain and headache that were probably ndt or only partially related to the masticatory system. Both were eventualiy referred for neurologic examination and treatment. In -one patiennt, the aggravating pain was finally diagnosed to be of pulpal origin in a fixed partia1 denture abutment2 Two patients had first been successfully treated but had experienced recurrences at the time of the review. The remaining four patients had obvious Ructiation of pain and dysfu6ction: relatively mild sympto& at first visit without need of treatment and later intensified signs and SEPTEMBER
1985
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54
NUMBER
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FACTORS
INFLUENCING
TMJ
TREATMENT
OUTCOME
Table III. Significant correlations between independent to Spearman rank correlation test (p < .Ol)
variables
and dependent
Dependent Independent
variables
No.
Social situation Tooth clenching Crepitatlon of TMJ Headache Dizziness (vertigo) Ear-buzzing, impaired hearing Tongue pain Number of reported symptoms Duration of initial symptoms Evaluation of initial symptoms Demand for treatment Sick leave because of symptoms Symptoms do not bother much Dysfunction index Tenderness on muscle palpation Limitation of mandibular mobility Occlusal interference index + = I’ositivc correlation correlation ill j> 5 .OOl.
aI 0.001
,/I 5 .Ol;
of visits
Length
NS + NS NS NS NS NS ++ NS + -
+ -
NS -
++ ++ ++
negative
Evaluation
correlation
+ NS
symptoms requiring treatment, including prosthetic rehabilitation in three. A new analysis of the records of the 24 patients who had more than 10 (range 11 to 25) visits during the treatment period was made. They comprised 18 women and six men, 19 to 68 years of age. The main explanation for the great number of visits was the type of treatment provided and the development of signs and symptoms. In seven patients, prosthetic rehabilitation requiring many visits was performed. Eight patients had fluctuating or recurrent signs and symptoms that called for repeated treatment periods, while another nine patients experienced no improvement initially and therefore had new treatment attempts. In one, the aggravating TMJ pain finally led to TM J meniscectomy. The evaluation of signs and symptoms at the last visit averaged no worse for this group than for the others.
at 0.001
/J 5 .Ol ; ++
at last
visit
NS NS NS his NS NS NS N5 NS NS NS NS NS NS NS NS NS
++ ++ +
-=
variables
of treatment
+ NS + + + + + ++ + ++
variables according
= posirive
correlalion
al /I 15 00 I; --
= Iwgaribc,
Table IV. Independent variables to explain variation of dependent variable, number of visits, according to multiple regression analysis (170 patients)*
Independent
variable
Tenderness on palpation Occlusal interference index Evaluation of initial symptoms Grinding of teeth Symptoms give much worry Occlusal index Number of teeth *Only variables tlt2 = 0.2x.
Type of relation + + + + + +
Significance regression coefficientt (p value)
of
<.OOOl <.OOOl <.0004 <.0026 <.0037 <.0037 <.0049
with ,/I < .Ol are listed.
DISCUSSION This study demonstrated a great variation in response to treatment as indicated by number of visits, length of treatment period, and evaluation of the patients’ signs and symptoms of mandibular dysfunction at the last visit. Our selection of a large group of patients for analysis enabled us to include both “simple” and “difficult” patients. All evaluations of the records were made by the same examiner, who tried to use only clear statements according to preset criteria. An example of this is the data in Table II; if any uncertainty existed between two THE
JOURNAL
OF PROSTHETIC
DENTISTRY
levels the lower one was always chosen. An attempt will be made in the future to estimate the uncertainty of the method when a group of these patients will be recalled to the clinic. In the follow-up studies of patients at the same clinic, the methodologic problems encountered have been reported. 23-21Patients’ recollection of original symptoms after 7 years was usually in agreement with notes in the patients’ records.24In a neurologic study of chronic-pain patients, the doctor’s global rating of the treatment effect was similar to patients’ self-rating.26 Such results might 423
WEDEI.
Table V. Independent variation of dependent treatment*
Independent
variable
Tenderness on muscle palpation Ear-nose-throat disease Grinding of teeth *ae
Evaluation of initial symptoms Heart or blood disease Limitation of mandibular mobility General state of health
variables to explain variable, length of
Type of relation
+ + +
Significance regression coeficientt (p value)
Table VI. Independent variation of dependent of signs and symptoms ~-___
<.OOOl < 0001 <.OOOl
+ -
<.0032 <.0044 <.0048
+ +
<.0068 < 0084
be taken as support for the method of evaluation used in this study, although the problems of clinical judgment is well known.27 However, the inclusion of specified psychologic and physiologic measures did not solve all methodologic problems in process and outcome studies of patients with dental fear. 2XTherefore, simple clinical evaluation, as used here in a systematized way, seems justified. The number of visits and the length of treatment period are closely correlated, but they differ in relation to other variables (Table III). The number of visits is correlated to more variables and more strongly to those which indicate severity of initial symptoms. The number of visits tends to imply need and demand of more specific treatment measures than the length of treatment period, which is also influenced by waiting periods in more chronic patients. Tenderness on muscle palpation at the first visit had the strongest influence and explained most of the variation of both these dependent variables. Several studies showed that muscle tenderness is the factor that best explains the severity of subjective and clinical dysfunction both in clinical and epidemiologic studies.3,ia29 The present results indicate that muscle tenderness on palpation at the first visit is also of equal importance to the number of visits and length of the treatment period, probably because these factors are influenced by the severity of the initial signs and symptoms. Dental and occlusal factors are correlated to the outcome of treatment only to a small degree in this patient series. This observation corroborates findings reported in other studies. “. 3o An addition index of the types of interference included in the occlusal indexj’ was
424
CARLSSON
variables to explain variable, evaluation at last visit*
of
Independent
AND
Type of relation
variable
Symptoms disturb work Heart or blood disease Maximal mouth opening Pain on movement of mandible
Significance regression coefficient* (p value)
-t
of
<.0004 <.0035 i.0044 <.(I064
--
positively correlated to number of visits; this factor was also of significant influence in the regression analysis (Tables III and IV). On the other hand, the occlusal index was negatively related and number of teeth positively related to the dependent variable (Table IV), which means that the more teeth a patient had, the more visits he made to the clinic. The evaluation of signs and symptoms at last visit was not significantly (la > .Ol) correlated to any of the variables in Table I when all patients were analyzed. In the regression analysis in about half the patients, the variables with, a significant influence had a low explanatory value (Table VI). Thus, the initial severity of dysfunction had no significant influence on the final evaluation after treatment. A possible explanation is that it is difficult to prognosticate the outcome of treatment by means of initial signs and symptoms. On the other hand, it is well acknowledged that both short- and long-term effects of simple treatment is favorable in most patients.” 23,‘4 Information of an usually good prognosis should be conveyed to the patients on initial counseling as positive assurance that they can be helped. The similarity of average treatment results in various subgroups (Table VII) and wide individual variations indicate the heterogeneity of the clientele and the impossible task to find a “typical” TM J disorder patient. It is interesting to note that the small group of patients (15 of 350) who considered locking or dislocation of the mandible (indicating a clinical diagnosis of disk displacement) to be the most troublesome symptom did not deviate as to outcome of treatment from those who had the diagnosis “mandibular dysfunction.” A similar observation of favorable prognosis for locking of the mandible was made in a 7-year follow-up.24 This indicates that it is not necessary to overdramatize this symptom. Only one of the 350 patients was referred for TM J surgery, which is in agreement with the restrictive~ attitude toward this treatment modality at the clinic.‘”
SEPTEMBER
1985
VOLUME
54
NUMBER
3
FACTORS
INFLUENCING
TMJ
TREATMENT
OUTCOME
Table VII. Means (jz) and medians (M) for number of visits, length of treatment (in months), and final evaluation of signs and symptoms; and medians of patients’ evaluation of severity of initial
symptoms,
clinical dysfunction
(Di), and occlusal index (0,)’ Number of visits
Patient
grow
-
Length of treatment
Final evaluationt
Initial symptoms M
Di
0;
M
M
No.
%
M
R
M
Iz
M
212 108 56 156
5.5 6.1 4.8 5.6
5 5 4 5
6.5 7.3 4.9 6.4
4 4 2.5 4
2.6 2.7 2.8 2.8
3 2.5 3 3
2 2 2 2
1 1 1 2
30
3.9
3.5
4.3
2
2.8
3
1
1
41 124
6.1 3.9
4 3.5
6.5 4.3
3 2
2.9 2.8
3 3
2 1
2 1
180 32 25 16
5.7 5.8 2.9 1.7
5 5 2 1
6.1 6.7 2.6 2.1
4 4 1 1
2.5 2.6 2.9 2.8
2 3 3 3
2 2 1 1
1 1 1 1.5
171
5.5
5
6.1
4
1.7
2
2
1
9 57
7.9 3.1
5 3
11.9 2.5
5 1
5.0 3.6
5 4
3 2
2 1
15 44 8
5.7 5.7 6.3
5 5 5
4.3 6.5 6.9
3 4.5 3
2.6 2.8 2.4
2 2.5 2
2 2 2.5
1 1 1.5
Sytrlytorns
Typical pain-dysfunction symptoms Peripheral, bizarre symptoms Headache as main symptom Duration of symptoms > 1 year C/inrcai
filldlrlg
Natural dentition without disturbances (0, = 0) Denture wearers Mild clinical dysfunction (D,=OorI) Dn~,ylll”lS Mandibular dysfunction TMJ disease Mainly clicking of TMJ Not referrable to masticatory system Outco~trr
of trcattnmt
Symptom free or marked improvement (scale value 1 or 2) Worse (scale value 5) Discontinuance of treatment; lack of cooperation Most froublesotne symptom Locking or dislocation of mandible Headache Ear buzzing (tinnitus)
SUMMARY review was performed in 350 consecutive patients referred for functional disturbances of the masticatory system. Two and one-half years after the first visit, the records of all patients were examined for clinical findings, diagnosis, and observations related to treatment. Number of visits, length of the treatment period, and evaluation of signs and symptoms at last visit (factors which showed a wide variation) were analyzed for correlation with signs and symptoms at first visit and some background factors. A total of 50 variables were considered. The number of visits and length of treatment period were primarily correlated with variables that indicated the severity of signs and symptoms at the first visit. Multiple regression analysis showed that tenderness on muscle palpation at first visit was the most important of the independent variables. About onefourth of the variance of number of visits and length of A retrospective
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
treatment could be explained (R’ = 0.28 and 0.27, respectively), while the corresponding value for the variance of the evaluation at last visit was 15% (R’ = 0.15). The results tend to emphasize the heterogeneity of patients with functional disturbances of the masticatory system and the difficulty of prognosticating the outcome of treatment in such patients, even when attempts are made to divide them into subgroups. REFERENCES I.
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SEPTEMBER
1985
VOLUME
54
NUMBER
3