TMD: Epidemiology: Signs and Symptoms Mauno Könönen Prof., Dr. Odont. Dept. of Stomatognathic Physiology and Prosthetic Dentistry Institute of Dentistry University of Helsinki Finland
Temporomandibular disorders (TMD)
Temporomandibular Disorders Definition: Temporomandibular disorders is a collective term embracing a number of clinical problems that involve the masticatory musculature, the TMJ and associated structures, or both. AAOP 1996
Classification of Orofacial Pains Axis I Axis II Diagnosis Classification of Orofacial Pains
Differental Diagnosis of Orofacial Pain Intracranial Pain Disorders Primary Headache Disorders Neurogenic Pain Disorders Intraoral Pain Disorders Temporomandibular Disorders Associated Structures Mental Disorders
Diagnostic classification Temporomandibular Joint Articular Disorders Masticatory Muscle Disorders
Somatic Pain Neuropathic Pain Superficial Pain Deep Pain Episodic Pain Continuous Pain Symphathetically Maintained Pain Deafferentation Pain Neuritis Pain Paroxysmal Neuralgia Pain Visceral Pain Musculoskeletal Pain Mucogingival Pain Cutaneous Pain Traumatic Neuralgia Atypical Odontalgia Postherpetic Neuralgia Herpes Zoster Peripheral Pain Neurovascular Pain Vascular Pain Pulpal Pain Visceral Mucosal Pain Glandular, Ocular and Auricular Pain Periodontal Pain Soft Connective Tissue Pain Osseous and Periosteal Pain Temporomandibular Joint Pain Muscle Pain Classification of Orofacial Pains
Traumatic Neuralgia Atypical Odontalgia Postherpetic Neuralgia Herpes Zoster Peripheral Pain Neurovascular Pain Vascular Pain Pulpal Pain Visceral Mucosal Pain Glandular, Ocular and Auricular Pain Periodontal Pain Soft Connective Tissue Pain Osseous and Periosteal Pain Temporomandibular Joint Pain Muscle Pain Migraine with Aura Migraine without Aura Cluster Headache Paroxysmal Hemicrania Neurovascular Variants Arteritis Pain Carotidynia Ligamentous Pain Retrodiscal Pain Capsular Pain Arthritic Pain Co-contraction Delayed Onset Muscle Pain Myofascial Pain Muscle Spams Pain Muscle Inflammation Pain Classification of Orofacial Pains
Tautiluokitus ICD-10 suomalainen tautiluokitus Maailman terveysjärjestön (WHO) luokituksesta tautien ja muiden terveysongelmien sanalliset diagnoosit koodeiksi tilastot ja tutkimustyö
Tautiluokituskoodeja (TMD)
History of TMD Costen syndrome, James Costen 1934 symptoms in masticatory and ear area first study to seek association between masticatory and symptoms in the ear region stydy comprised 11 patients, no controls patients had decreased vertical dimension of occlusion treatment: increase vertical dimesion of occlusion anatomist Sicher showed that occlusion cannot cause impingement of n. auriculotemporalis
History of TMD 50 ies increased interest towards TMD muscle tenderness and pain caused by occlusion 60 ies: occlusion and stress 70 ies: more focus on pain in TM joint 80 ies: TMD is complex and multifactorial dentist s role in orofacial pain questioned
Temporomandibular Disorders Costen syndrome Temporomandibular joint (TMJ) disturbances TMJ dysfunction syndrome Functional TMJ disturbances Occluso-mandibular disturbances Myoarthropathy of TMJ Pain-dysfunction syndrome Myofascial pain-dysfunction TMJ-pain dysfunction syndrome Arthrosis deformans Oto-dental syndrome Autodestruction Craniomandibular disorders
Epidemiology of TMD about 33% at least one symptom from 40% to 70% at least one sign about 30% clicking TMD decreases in older age ratio men:women 1:3 to 1:9 seeking care only 3% to 7% in need of treatment natural history???????
Epidemiology
Helkimo s Clinical Dysfunction Index A. Mobility index (0, 1, 5) B. TMJ function (0, 1, 5) C. Muscle pain (0, 1, 5) D. TMJ pain (0, 1, 5) E. Pain on movement (0, 1, 5) Sum A+B+C+D+E = Dysfunction Score (0-25 points) Clinical Dysfunction Index Di, according to code: 0 points = clinically symptom free= Di 0 1-4 points = mild dysfunction = Di I 5-9 points = moderate dysfunction = Di II 10-25 points = severe dysfunction = Di III
Reported symptoms of mandibular dysfunction: median values and range of percentage frequencies in 18 studies Symptom median range TMJ sounds 19 6-48 Tenderness, stiffness of jaws 11 7-19 Pain: mandibular function 6 3-21 Limitation of jaw movement 8 5-14 Locking of TMJ 4 <1-7 Frequent headache 17 5-29 Carlsson 1984
Clinical signs of mandibular dysfunction: median values and range of percentage frequencies in 18 studies Clinical finding median range TMJ sounds 26 9-50 Palpation tenderness: masticatory muscles 33 16-64 TMJ 14 1-39 Pain:mandibular movement 4 2-10 Limitation of jaw movement 7 4-18 Carlsson 1984
Epidemiology
Epidemiology
Epidemiology of TMD
TMD: Seeking care
Epidemiology: seeking care 3400 patients 360.000 enrollees men 33.8 yrs women 34.2 yrs 85.4 % women
Epidemiology: Why women? Women: all patient clinics Psychosocial factors - women seek care Recently - women more signs and symptoms Physiologic factors? Hormonal factors?
Sex differences in the use health care services NEJM 1997?
Sex differences in the use TMD health care services
Epidemiology (Kuttila 1998)
TMD Classification Muscle disorders Disc problems Joint diseases
Polyarthritides (ICM.9.CM 714.9) Rheumatoid arthritis Juvenile chronic arthritis Ankylosing spondylitis Psoriatic arthritis Reiter s disease Infectious arthritis Crystal induced disease Scleroderma Sjögren s syndrome Lupus erythematosus
CRANIOMANDIBULAR DISORDERS IN PSORIATIC ARTHRITIS A radiographic and clinical study Mauno Könönen Helsinki 1987
Psoriatic arthritis: Erosion in right TMJ
TMD Classification Muscle disorders Disc problems Joint diseases
Lateral view of TMJ Intercuspal position Opening of mouth
Coronal view of TMJ
Definition of TMJ clicking Temporomandibular joint clicking is defined as a distinct snapping or popping sound emanating from the TMJ during joint movement or with joint compression Okeson 1996
Sounds from TMJ Common causes for clicking disc dislocation deviation in form muscle co-ordination problem Common causes for crepitation arthrosis inflammatory joint diseases
Longitudinal variation in reported TMJ clicking sounds in young Finns (n=128) Könönen et al: THE LANCET 1996; 347: 1080-1081
Longitudinal variation in recorded TMJ clicking sounds in young Finns (n=128) Könönen et al: THE LANCET 1996; 347: 1080-1081
TMD Classification Muscle disorders Disc problems Joint diseases
Masticatory Muscle Disorders Myofascial pain chronic regional muscle pain complaint of pain tenderness to palpation with replication of chief complaint pain increased by mandibular function or parafunction Affected ROM possible presence of trigger points
Age (years) 14 15 18 23 YES 4 2 2 16 14 14 11 Orofacial pain 10 12 9 12 12 12 NO 112 102 114 114 117 102 105 (n=128)
Age (years) 14 15 18 23 YES 8 7 7 27 19 24 21 Muscle tenderness 11 17 14 19 12 17 NO 101 90 109 104 107 92 90 (n=128)
9-Year Follow-Up of TMD in Young Finnish Adults
Temporomandibular Disorders: To treat or not to treat?