j m CURRENT
a
CLINICAL
PRACTICE
T H H DISORDERS
An epidemiologic study of clinical signs and symptoms of temporomandibular disorders (TMD) was conducted with a probability sample of adults enrolled in a major health maintenance organization (HMO). This report presents data from a first wave field examination and interview conducted by trained, calibrated dental hygienist field examiners. Significant gender differences for vertical jaw opening measures were observed but no significant age differences were found for the distribution of clinically relevant findings. Clinic cases showed smaller amounts of vertical range of jaw motion but did not differ from community cases or controls on extent of lateral, protrusive, or retrusive mandibular movements; on classification of occlusion; or on dentally related variables. Clinic cases had more pain during all jaw excursions as well as during muscle and joint palpation. Joint clicking sounds were also observed more frequently in clinic cases.
Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in cases and controls Samuel F. Dworkin, DDS, PhD; Kimberly H. Huggins, RD H , BS; Linda LeResche, ScD; Michael Von Korff, ScD; James Howard, DDS; Edmond Truelove, DDS, MSD; Earl Sommers, DDS, MSD
T
e m p o r o m a n d i b u l a r d is o r d e r s a re
th e d e s c r ip t iv e e p i d e m i o lo g y o f c h r o n i c
a n d s t a n d a r d iz a t io n o f t h e i r e x a m i n a t i o n
r e c o g n iz e d a s th e m o s t c o m m o n
p a i n c o n d i t i o n s i n g e n e r a l, 2 a n d o f T M D
m e th o d s . T h e
c h r o n ic o r o f a c ia l p a in
in
s u c h r e lia b ilit y
t io n s c o n f r o n t in g
d e n t is t s
h e a lt h c a re p r o v id e r s . A A m e r ic a n
and
o th e r
r e p o r t b y th e
D e n t a l A s s o c ia t io n 1 h a s s u g
p a r t ic u la r . 3 T h e
u lt im a t e
a im
of
e p id e m io lo g ic s t u d ie s is to p r o v id e
a
s c i e n t i f i c b a s is f o r e f fo r t s to p r e v e n t a n d c o n t r o l d is e a s e , i ll n e s s , a n d d i s a b i l i t y . 4
c o n s id e r e d
e p i d e m i o lo g y s t u d ie s . 7 T o a d d r e s s th e l a c k o f a d e q u a t e e p id e m io lo g ic
d a ta , w e a re c o n d u c t in g
th e
d is o r d e r s ( T M D ) r e f e r s t o a c l u s t e r o f
d is e a s e c a n n o t b e u n d e r s t o o d w i t h o u t
f ir s t e p id e m io lo g ic
d is o r d e r s c h a r a c t e r iz e d b y : p a i n
in v e s t ig a t in g
th e U n i t e d S ta t e s t h a t u s e s i d e n t i c a l s t u d y
th e
o f e p id e m io lo g y is th a t
d a ta is n o w
e s s e n t ia l w h e n r e p o r t i n g r e s u lt s o f d e n t a l
A
in
b a s ic a x i o m
r e q u ir e m e n t to p r o v id e
g e ste d th a t th e te r m t e m p o r o m a n d ib u la r
it s e x p r e s s io n
in
popu
s tu d y
of T M D
l a t i o n s a s w e l l a s p e r s o n s s e e k in g tr e a t
m e th o d s
u la r j o in t
m e n t .5 R e v ie w s o f th e a v a ila b le e p id e
b o t h s y m p t o m a t ic a n d s e e k in g t r e a t m e n t
(T M J),
or
th e
in
m u s c le s
of
o r d e v ia t io n s
m a n d ib u la r r a n g e o f m o t io n ; a n d
n o is e s i n
th e T M J
d u r in g
f u n c t io n . I n a d d it io n
m a n d ib u la r
to t h is
t r ia d o f
m io lo g ic
s t u d ie s
of T M D
s ig n s
and
to c o m p a r e p a t ie n t s w h o
in
p r e a u r i c u l a r a r e a , t h e t e m p o r o m a n d ib m a s t ic a t io n ; lim it a t io n s i
c o n d i
( c lin ic ca se s) w it h
r a n d o m ly
p e rso n s fro m
th e s a m e c o m m u n i t y w h o
b e c a u s e th e y fo c u s la r g e ly o n
re p o rt T M D
p a in
s a m p le s
o f p a t ie n t s s e e k in g t r e a t m e n t o r b e c a u s e
( c o m m u n it y
th e y w e r e c o n d u c t e d o n c o n v e n ie n c e
w h o a r e fre e o f T M D
s a m p le s o r o t h e r n o n r e p r e s e n t a t iv e p o r
c o n t r o ls ) .
E p id e m io lo g ic
d e n t is t s a s s o c ia t e w i t h
t io n s o f th e p o p u la t io n . 6 I n a d d it io n ,
d e s c r ib e d
fo r
fin d in g s
a re
ra n g e
o f m o t io n , j o in t
s o u n d s , c la s s if ic a t io n
o f o c c lu s io n , a n d
p a i n e lic it e d b y f u n c t i o n a n d b y p a l p a t i o n
t h e s e s t u d ie s v a r y w i d e l y
d u c i b i l i t y o f m e t h o d s u s e d t o g a t h e r d a ta .
re sp o n se
m al
W hen
c lin ic a l e x a m in a t io n s a re p e r
m a s t ic a t o r y , a n d a d j a c e n t m u s c le s , b a s e d
f o r m e d , d a t a a r e r a r e ly p r o v id e d r e g a r d in g
o n e x a m in a t io n o f c l in i c a n d c o m m u n it y
th e r e l i a b i l i t y
c a se s a n d c o m m u n i t y c o n t r o ls . W e a ls o
and
d y n a m ic
o c c lu s a l
r e la t io n s h ip s . T h e r e is a p a u c it y
o f d a t a r e g a r d in g
th e r e p r o
p a i n ( c o m m u n it y
o f th e m u s c le s o f m a s t i c a t i o n a n d a b n o r s t a t ic
in
c a se s),
a n d w i t h p e r s o n s i n th e s a m e c o m m u n i t y
s o u n d s , a d d it io n a l c lin ic a l fa c to rs th a t in c lu d e :
s e le c t e d
s y m p t o m s h a v e f o u n d th e s t u d ie s l a c k in g
p a in , m a n d ib u l a r d y s f u n c t io n , a n d j o i n t T M D
a re
o f th e c l i n i c a l e x a m in e r s
to
p a lp a t io n
of
th e
T M J,
JADA, Vol. 120, March 1990 ■ 273
CURRENT
CLINICAL
PRACTICE
i n c lu d e d e s c r ip t iv e d a t a f o r s e lf - r e p o r t
w a y , a n d a 5 -y e a r f o l l o w - u p is p la n n e d .
r e g a r d in g
o f j o i n t s o u n d s , lo c k in g , a n d p a in d u r in g
T h e o v e r a ll d e s ig n o f t h is e p i d e m i o lo g i c
d u r a t i o n , in t e r f e r e n c e , a n d a c t iv i t y
f u n c t io n . S u b s e q u e n t r e p o r ts w i l l p re s e n t
s tu d y , t h r o u g h
it a t i o n . A l s o i n c l u d e d w e r e it e m s o n s ig n s
d e t a ile d
p r e s e n t e d s c h e m a t ic a lly i n F i g u r e 1.
d e s c r ip t iv e
a n a ly s e s
o f p a in
th e
1 y e a r f o l lo w - u p , is
lim
a n d s y m p t o m s o f T M D , s o c io d e m o g r a
s y m p t o m s a n d o t h e r s e lf - r e p o r t f i n d i n g s
p h i c it e m s , a n d a 6 0 - it e m v e r s io n o f th e
g a t h e r e d b y in t e r v ie w w i t h th e s a m e c a s e s
Screening phase. A n a g e - s t r a t if ie d p r o b
H o p k in s
a n d c o n t r o ls
a b i l i t y s a m p le o f a d u lt e n r o lle e s o f G r o u p
p s y c h o lo g i c a l d is tr e s s . T h e q u e s t io n n a ir e
H e a lt h
w as in it ia lly
a s w e l l a s t h e r e s u lt s o f
1- a n d 3 - y e a r f o l l o w - u p and
in t e r v ie w s . O u r
e x a m in a t io n s
C o o p e r a t iv e
of
Puget
Sound
t h is
( G H C ) , a g e d 18 to 75 y e a r s , w a s id e n t i f i e d
s e r ie s o f d e s c r i p t i v e s t u d ie s , is to m a k e
t o r e c e iv e th e s c r e e n in g s u r v e y q u e s t i o n
a v a i l a b le r e l i a b le a n d v a l i d p o p u l a t i o n -
n a ir e . T h e G H C
based
3 2 0 ,0 0 0 e n r o lle e s ) is s i m i l a r d e m o g r a p h -
T M D
d a ta
in t e n t , w it h
fo r
c lin ic ia n s
and
r e s e a r c h e r s to a i d t h e i r o w n u n d e r s t a n d
ic a lly
i n g o f th e n a t u r e o f th e s e d is o r d e r s .
K in g
Study design and methods re se a rch
p o p u la t io n
p la n
fo r
o f th e S e a t t le -
C o u n t y r e g io n . A m o n g
th e
th e s a m p le e lig ib le
1 ,265
f o r th e
s u r v e y , q u e s t i o n n a i r e s w e r e c o m p le t e d by
The
p o p u la t io n (m o re th a n
to t h e p o p u l a t i o n
p e rs o n s in
DISORDERS
i n t e n s i t y , p e r s is t e n c e , d a i l y
t h is
o n g o in g
b a se d s tu d y o f T M D
p a in
1 ,016 p e r s o n s , f o r a r e s p o n s e r a te o f
80.3% . The
S y m p to m
C h e c k li s t , 8 to a sse ss
p re te ste d o n b o th
T M D
p a t ie n t s a n d p e r s o n s w i t h o u t T M D p a in . The
s u r v e y i d e n t if ie d , i n
s a m p le o f r e s p o n d e n t s ,
th e r a n d o m
123 c o m m u n i t y
c a se s o f T M D p a i n (12.1% o f th e s a m p le ) , d e f in e d as th o s e w h o r e p o r t e d “ f a c ia l a c h e o r p a in j o in t in
in
th e ja w
m u s c le s , t h e
f r o n t o f th e e a r o r in s id e
th e
e a r ( o t h e r t h a n i n f e c t i o n ) ” i n th e p r e v io u s 6 m o n t h s . 9 M o s t o f th e se c o m m u n it y c a se s w e r e n o t c u r r e n t ly u n d e r t r e a t m e n t
s c r e e n in g s u r v e y i n s t r u m e n t w a s
f o r T M D . A l l 123 c o m m u n i t y c a se s w e r e
in v o lv e s f o u r p h a s e s : a s c r e e n in g s u r v e y
d e s ig n e d to i d e n t i f y p e r s o n s w i t h T M D
re fe rre d fo r f ie ld e x a m in a t io n a n d in t e r
p h a s e to i d e n t i f y c a s e s i n th e c o m m u n i t y
p a i n f r o m a m o n g th e G H C
v ie w b y th e d e n t a l h y g i e n is t in t e r v ie w e r s
r e p o r t in g T M D
T h e s u r v e y q u e s t i o n n a ir e i n c l u d e d i d e n
w o r k in g o n
c o n d i t i o n s ; t r a i n i n g o f r e l i a b le e x a m i n e r /
t ic a l b a t t e r ie s o f it e m s o n
c o m m u n i t y c o n t r o ls , s e le c te d a t r a n d o m
i n t e r v ie w e r s to g a t h e r c l i n i c a l a n d i n t e r
com m on
c o n d it io n s : b a c k p a in ,
fro m
th o s e w h o
v ie w
h e a d a c h e , a b d o m in a l a n d c h e s t p a in ,
p a in
in
in a d d it io n to T M D
id e n t if ie d
d a ta
r e lia b ilit y a
f ir s t
in
a n d o th e r c h r o n ic p a in
th e
f ie ld
and
to
assess
o f th e c l in i c a l e x a m in a t io n ;
w ave
f ie ld
e x a m in a t io n
and
p a in
p o p u la t i o n . fo u r o th e r
p a in . S u b je c t s w e r e
in s t r u c t e d n o t to r e p o r t f le e t in g o r m i n o r
d id
s a m p le o f 2 6 4
n o t re p o rt T M D
th e p a s t 6 m o n t h s , w e re a ls o t o r e c e iv e a f i e l d
in t e r v ie w
a n d e x a m in a t io n .
in t e r v ie w ; a n d a s e c o n d w a v e , 1 -y e a r
a c h e s o r p a in s , o r c o n d it io n s
f o llo w - u p
o c c u r r e d o n ly o n a s in g le d a y . F o r e a ch
c o n s e c u t iv e ly b y G H C
p a in c o n d it io n , in f o r m a t io n w a s g a th e re d
T M D , w e r e i d e n t i f i e d f o r in t e r v ie w
A
e x a m in a t io n
a n d in t e r v ie w .
s u b s e q u e n t 3 -y e a r f o llo w u p
is
under
th a t h a d
th e s tu d y . A
A d d i t i o n a l l y , 2 8 9 c l i n i c case s, r e f e r r e d
e x a m in a t io n
fo r tre a tm e n t o f and
b y s t u d y h y g ie n is t s . T h e s e
p e r s o n s w e r e a l s o s e n t s c r e e n in g q u e s t io n n a ir e s ; 83.7% w e r e c o m p le t e d .
SAMPLE
REFERRALS TO
SURVEY
Field examination and interview, wave I. A f ie ld
Al l GHC TMD Re f e r r a l s
GHC En r o l l e e s : Random S ample
N = 289
N = 1265
e x a m in a t io n
a s s e s s in g s i g n s a n d
s y m p to m s o f T M D , in c lu d in g
m a n d ib
u la r r a n g e o f m o t io n , j o in t s o u n d s , p a in o n p a l p a t i o n , a n d p a i n o n f u n c t i o n , as
S c r e e n in g
S c r e e n in g
Qu e s t io n n a ir e
w e l l as d e n t a l, p e r io d o n t a l, a n d o c c lu s a l
Qu e s t io n n a ir e
N = 1016 (80.3%)
v a r ia b le s ,
H = 242 (83.7%)
30% S am ple
a lo n g
is t s w h o s e rv e as f i e l d
Fig 1 ■ Study design: epidem iologic studies of TMD.
Y ES 100% S ample
n a t io n
p ro c e d u re s
in
and
th e e x a m i
c a lib r a t e d
th e v a r ia b le s c o v e r e d b y E x t e n s iv e
th e e x a m
r e lia b ilit y
s t u d ie s
c o m p a r in g th e s e t r a in e d e x a m in e r s w i t h u n c a lib r a t e d c lin ic a l e x p e rts in w e r e c o n d u c t e d 10-11 u s i n g
N=210 (79.6%)
Community Ca s e s
N=121 (88.3%)
Cl i n i c Ca s e s
N=261 (90.3%)
s y m p t o m s b e i n g a sse ssed . E a c h e x a m in e r sa w
e a c h s u b je c t in
in a t io n
N=220 (89.8%)
a b a l a n c e d d e s ig n
th e e ffe c ts o f o r d e r o f e x a m to b e d e t e r m i n e d . R e t r a i n i n g
t o o k p la c e o n th o s e v a r ia b le s f o r w h i c h r e lia b ilit y
N=109 (95.6%)
T M D
s a m p le s o f
s u b je c t s w i t h a n d w i t h o u t th e s ig n s a n d
to a llo w
On e -Y ear Follow Up Exam in a t io n / I n terv iew
to
a c c e p t a b le le v e ls o f r e l i a b i l i t y f o r a sse ss in a t io n .
F i e l d Ex a m in a tio n / I nterv iew
in t e r v ie w e r s a n d
e x a m in e r s w e re t r a in e d
in g
Community Co n tro ls
w it h
p r o c e d u r e s . F o u r r e g is te r e d d e n t a l h y g i e n
Fa c ia l p a i n ?
V
w a s d e v e lo p e d
d e t a i le d s p e c i f i c a t i o n s f o r e x a m i n a t i o n
w a s in it ia lly
in a d e q u a t e a n d
r e l i a b i l i t y w a s re te s te d o n a n e w s a m p le . These
p ro ce d u re s
a p p r o x im a t e ly
w e re
6 -m o n th
re p e a te d
at
in t e r v a ls
t h r o u g h o u t th e s t u d y . F i e l d e x a m i n e r s
274 ■ JADA, Vol. 120, March 1990
CURRENT
CLINICAL
PRACTICE
a c h ie v e d a c c e p t a b le to e x c e lle n t r e l i a b i l i t y
o r p e rc e n t o f o c c u rre n c e fo r e a ch ca te g o ry
ty p e ( t h a t is , C L C A ,
o n a l l v a r ia b le s e x c e p t as n o t e d i n s p e c if ic
is p r o v id e d .
f e m a le s s h o w e d s i g n i f i c a n t l y
w a s d e v e lo p e d a n d p re te s te d to o b t a in in f o r m a t io n
on
u n a s s is t e d
f i e ld in t e r v ie w
Demographic description
m e a su re d in
l o g i c a l fa c t o r s t h a t h a v e b e e n p r o p o s e d
T h e r e w e re n o s t a t is t ic a lly
as p o s s ib le r is k
s ig n if ic a n t
in c is o r s
f a c t o r s o r s e q u e la e o f
d if f e r e n c e s b e t w e e n c a s e ty p e s w i t h r e g a r d
4 to 5 m m
to a g e ( o v e r a ll m e a n a g e = 3 9 y e a rs ) ,
m a x im u m
and
h is t o r y , p s y c h o s o c i a l v a r ia b le s , a n d
e t h n ic it y , o r l i v i n g
m a le s i n
th e C L C A
d id
o f th e T M D p a i n p r o b l e m a m o n g p e r s o n s
fo r
v e r t ic a l o p e n in g ;
w it h T M D .
m a r it a l s ta tu s , a n d g e n d e r. T h e
The
W a v e I F ie ld
and
g r o u p w e r e le s s l i k e l y
g ro u p s
m a le s i n
th e C O C O
i m u m a s s is te d j a w o p e n i n g t h a n f e m a le s
in c o m e s g r e a t e r t h a n $ 3 5 ,0 0 0 ; th e y w e r e a ls o m o r e l i k e l y
and C O C A
s i g n i f i c a n t d if f e r e n c e s i n
to h a v e a tte n d e d
case s a n d c o m m u n it y c o n t r o ls th e s c r e e n in g s u r v e y ,
not show
g r o u p s h o w e d s ig n if ic a n t ly g re a te r m a x
s c h o o l p a s t c o lle g e o r to h a v e h o u s e h o ld
id e n t if ie d t h r o u g h
1). F o r
C LC A
w a s a d m in is t e r e d to th e c o m
I n t e r v ie w m u n it y
E x a m in a t io n
e m p lo y m e n t ,
m a n d ib u la r c e n tr a l
w a s o b s e r v e d ) ( T a b le
t i s t i c a l l y s i g n i f i c a n t d if f e r e n c e s e m e r g e d in c o m e ,
s m a lle r m o t io n ,
a s s is te d o p e n i n g , f e m a le s a n d
s u b je c t ’ s u n d e r s t a n d in g o f th e n a tu r e
e d u c a t io n ,
of
(a g e n d e r d if f e r e n c e o f a b o u t
T M D , a s w e l l as p a i n r e p o r t , t r e a t m e n t
a rra n g e m e n ts. S ta
ra n g e
m illim e t e r s b e tw e e n ed g e s
o f m a x illa r y
p h y s ic a l a n d p s y c h o
th e
v e r t ic a l
CO CO )
to b e u n e m p l o y e d (8%
(P
a
CLINICAL
PRACTICE
T H H DISORDERS
An epidemiologic study of clinical signs and symptoms of temporomandibular disorders (TMD) was conducted with a probability sample of adults enrolled in a major health maintenance organization (HMO). This report presents data from a first wave field examination and interview conducted by trained, calibrated dental hygienist field examiners. Significant gender differences for vertical jaw opening measures were observed but no significant age differences were found for the distribution of clinically relevant findings. Clinic cases showed smaller amounts of vertical range of jaw motion but did not differ from community cases or controls on extent of lateral, protrusive, or retrusive mandibular movements; on classification of occlusion; or on dentally related variables. Clinic cases had more pain during all jaw excursions as well as during muscle and joint palpation. Joint clicking sounds were also observed more frequently in clinic cases.
Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in cases and controls Samuel F. Dworkin, DDS, PhD; Kimberly H. Huggins, RD H , BS; Linda LeResche, ScD; Michael Von Korff, ScD; James Howard, DDS; Edmond Truelove, DDS, MSD; Earl Sommers, DDS, MSD
T
e m p o r o m a n d i b u l a r d is o r d e r s a re
th e d e s c r ip t iv e e p i d e m i o lo g y o f c h r o n i c
a n d s t a n d a r d iz a t io n o f t h e i r e x a m i n a t i o n
r e c o g n iz e d a s th e m o s t c o m m o n
p a i n c o n d i t i o n s i n g e n e r a l, 2 a n d o f T M D
m e th o d s . T h e
c h r o n ic o r o f a c ia l p a in
in
s u c h r e lia b ilit y
t io n s c o n f r o n t in g
d e n t is t s
h e a lt h c a re p r o v id e r s . A A m e r ic a n
and
o th e r
r e p o r t b y th e
D e n t a l A s s o c ia t io n 1 h a s s u g
p a r t ic u la r . 3 T h e
u lt im a t e
a im
of
e p id e m io lo g ic s t u d ie s is to p r o v id e
a
s c i e n t i f i c b a s is f o r e f fo r t s to p r e v e n t a n d c o n t r o l d is e a s e , i ll n e s s , a n d d i s a b i l i t y . 4
c o n s id e r e d
e p i d e m i o lo g y s t u d ie s . 7 T o a d d r e s s th e l a c k o f a d e q u a t e e p id e m io lo g ic
d a ta , w e a re c o n d u c t in g
th e
d is o r d e r s ( T M D ) r e f e r s t o a c l u s t e r o f
d is e a s e c a n n o t b e u n d e r s t o o d w i t h o u t
f ir s t e p id e m io lo g ic
d is o r d e r s c h a r a c t e r iz e d b y : p a i n
in v e s t ig a t in g
th e U n i t e d S ta t e s t h a t u s e s i d e n t i c a l s t u d y
th e
o f e p id e m io lo g y is th a t
d a ta is n o w
e s s e n t ia l w h e n r e p o r t i n g r e s u lt s o f d e n t a l
A
in
b a s ic a x i o m
r e q u ir e m e n t to p r o v id e
g e ste d th a t th e te r m t e m p o r o m a n d ib u la r
it s e x p r e s s io n
in
popu
s tu d y
of T M D
l a t i o n s a s w e l l a s p e r s o n s s e e k in g tr e a t
m e th o d s
u la r j o in t
m e n t .5 R e v ie w s o f th e a v a ila b le e p id e
b o t h s y m p t o m a t ic a n d s e e k in g t r e a t m e n t
(T M J),
or
th e
in
m u s c le s
of
o r d e v ia t io n s
m a n d ib u la r r a n g e o f m o t io n ; a n d
n o is e s i n
th e T M J
d u r in g
f u n c t io n . I n a d d it io n
m a n d ib u la r
to t h is
t r ia d o f
m io lo g ic
s t u d ie s
of T M D
s ig n s
and
to c o m p a r e p a t ie n t s w h o
in
p r e a u r i c u l a r a r e a , t h e t e m p o r o m a n d ib m a s t ic a t io n ; lim it a t io n s i
c o n d i
( c lin ic ca se s) w it h
r a n d o m ly
p e rso n s fro m
th e s a m e c o m m u n i t y w h o
b e c a u s e th e y fo c u s la r g e ly o n
re p o rt T M D
p a in
s a m p le s
o f p a t ie n t s s e e k in g t r e a t m e n t o r b e c a u s e
( c o m m u n it y
th e y w e r e c o n d u c t e d o n c o n v e n ie n c e
w h o a r e fre e o f T M D
s a m p le s o r o t h e r n o n r e p r e s e n t a t iv e p o r
c o n t r o ls ) .
E p id e m io lo g ic
d e n t is t s a s s o c ia t e w i t h
t io n s o f th e p o p u la t io n . 6 I n a d d it io n ,
d e s c r ib e d
fo r
fin d in g s
a re
ra n g e
o f m o t io n , j o in t
s o u n d s , c la s s if ic a t io n
o f o c c lu s io n , a n d
p a i n e lic it e d b y f u n c t i o n a n d b y p a l p a t i o n
t h e s e s t u d ie s v a r y w i d e l y
d u c i b i l i t y o f m e t h o d s u s e d t o g a t h e r d a ta .
re sp o n se
m al
W hen
c lin ic a l e x a m in a t io n s a re p e r
m a s t ic a t o r y , a n d a d j a c e n t m u s c le s , b a s e d
f o r m e d , d a t a a r e r a r e ly p r o v id e d r e g a r d in g
o n e x a m in a t io n o f c l in i c a n d c o m m u n it y
th e r e l i a b i l i t y
c a se s a n d c o m m u n i t y c o n t r o ls . W e a ls o
and
d y n a m ic
o c c lu s a l
r e la t io n s h ip s . T h e r e is a p a u c it y
o f d a t a r e g a r d in g
th e r e p r o
p a i n ( c o m m u n it y
o f th e m u s c le s o f m a s t i c a t i o n a n d a b n o r s t a t ic
in
c a se s),
a n d w i t h p e r s o n s i n th e s a m e c o m m u n i t y
s o u n d s , a d d it io n a l c lin ic a l fa c to rs th a t in c lu d e :
s e le c t e d
s y m p t o m s h a v e f o u n d th e s t u d ie s l a c k in g
p a in , m a n d ib u l a r d y s f u n c t io n , a n d j o i n t T M D
a re
o f th e c l i n i c a l e x a m in e r s
to
p a lp a t io n
of
th e
T M J,
JADA, Vol. 120, March 1990 ■ 273
CURRENT
CLINICAL
PRACTICE
i n c lu d e d e s c r ip t iv e d a t a f o r s e lf - r e p o r t
w a y , a n d a 5 -y e a r f o l l o w - u p is p la n n e d .
r e g a r d in g
o f j o i n t s o u n d s , lo c k in g , a n d p a in d u r in g
T h e o v e r a ll d e s ig n o f t h is e p i d e m i o lo g i c
d u r a t i o n , in t e r f e r e n c e , a n d a c t iv i t y
f u n c t io n . S u b s e q u e n t r e p o r ts w i l l p re s e n t
s tu d y , t h r o u g h
it a t i o n . A l s o i n c l u d e d w e r e it e m s o n s ig n s
d e t a ile d
p r e s e n t e d s c h e m a t ic a lly i n F i g u r e 1.
d e s c r ip t iv e
a n a ly s e s
o f p a in
th e
1 y e a r f o l lo w - u p , is
lim
a n d s y m p t o m s o f T M D , s o c io d e m o g r a
s y m p t o m s a n d o t h e r s e lf - r e p o r t f i n d i n g s
p h i c it e m s , a n d a 6 0 - it e m v e r s io n o f th e
g a t h e r e d b y in t e r v ie w w i t h th e s a m e c a s e s
Screening phase. A n a g e - s t r a t if ie d p r o b
H o p k in s
a n d c o n t r o ls
a b i l i t y s a m p le o f a d u lt e n r o lle e s o f G r o u p
p s y c h o lo g i c a l d is tr e s s . T h e q u e s t io n n a ir e
H e a lt h
w as in it ia lly
a s w e l l a s t h e r e s u lt s o f
1- a n d 3 - y e a r f o l l o w - u p and
in t e r v ie w s . O u r
e x a m in a t io n s
C o o p e r a t iv e
of
Puget
Sound
t h is
( G H C ) , a g e d 18 to 75 y e a r s , w a s id e n t i f i e d
s e r ie s o f d e s c r i p t i v e s t u d ie s , is to m a k e
t o r e c e iv e th e s c r e e n in g s u r v e y q u e s t i o n
a v a i l a b le r e l i a b le a n d v a l i d p o p u l a t i o n -
n a ir e . T h e G H C
based
3 2 0 ,0 0 0 e n r o lle e s ) is s i m i l a r d e m o g r a p h -
T M D
d a ta
in t e n t , w it h
fo r
c lin ic ia n s
and
r e s e a r c h e r s to a i d t h e i r o w n u n d e r s t a n d
ic a lly
i n g o f th e n a t u r e o f th e s e d is o r d e r s .
K in g
Study design and methods re se a rch
p o p u la t io n
p la n
fo r
o f th e S e a t t le -
C o u n t y r e g io n . A m o n g
th e
th e s a m p le e lig ib le
1 ,265
f o r th e
s u r v e y , q u e s t i o n n a i r e s w e r e c o m p le t e d by
The
p o p u la t io n (m o re th a n
to t h e p o p u l a t i o n
p e rs o n s in
DISORDERS
i n t e n s i t y , p e r s is t e n c e , d a i l y
t h is
o n g o in g
b a se d s tu d y o f T M D
p a in
1 ,016 p e r s o n s , f o r a r e s p o n s e r a te o f
80.3% . The
S y m p to m
C h e c k li s t , 8 to a sse ss
p re te ste d o n b o th
T M D
p a t ie n t s a n d p e r s o n s w i t h o u t T M D p a in . The
s u r v e y i d e n t if ie d , i n
s a m p le o f r e s p o n d e n t s ,
th e r a n d o m
123 c o m m u n i t y
c a se s o f T M D p a i n (12.1% o f th e s a m p le ) , d e f in e d as th o s e w h o r e p o r t e d “ f a c ia l a c h e o r p a in j o in t in
in
th e ja w
m u s c le s , t h e
f r o n t o f th e e a r o r in s id e
th e
e a r ( o t h e r t h a n i n f e c t i o n ) ” i n th e p r e v io u s 6 m o n t h s . 9 M o s t o f th e se c o m m u n it y c a se s w e r e n o t c u r r e n t ly u n d e r t r e a t m e n t
s c r e e n in g s u r v e y i n s t r u m e n t w a s
f o r T M D . A l l 123 c o m m u n i t y c a se s w e r e
in v o lv e s f o u r p h a s e s : a s c r e e n in g s u r v e y
d e s ig n e d to i d e n t i f y p e r s o n s w i t h T M D
re fe rre d fo r f ie ld e x a m in a t io n a n d in t e r
p h a s e to i d e n t i f y c a s e s i n th e c o m m u n i t y
p a i n f r o m a m o n g th e G H C
v ie w b y th e d e n t a l h y g i e n is t in t e r v ie w e r s
r e p o r t in g T M D
T h e s u r v e y q u e s t i o n n a ir e i n c l u d e d i d e n
w o r k in g o n
c o n d i t i o n s ; t r a i n i n g o f r e l i a b le e x a m i n e r /
t ic a l b a t t e r ie s o f it e m s o n
c o m m u n i t y c o n t r o ls , s e le c te d a t r a n d o m
i n t e r v ie w e r s to g a t h e r c l i n i c a l a n d i n t e r
com m on
c o n d it io n s : b a c k p a in ,
fro m
th o s e w h o
v ie w
h e a d a c h e , a b d o m in a l a n d c h e s t p a in ,
p a in
in
in a d d it io n to T M D
id e n t if ie d
d a ta
r e lia b ilit y a
f ir s t
in
a n d o th e r c h r o n ic p a in
th e
f ie ld
and
to
assess
o f th e c l in i c a l e x a m in a t io n ;
w ave
f ie ld
e x a m in a t io n
and
p a in
p o p u la t i o n . fo u r o th e r
p a in . S u b je c t s w e r e
in s t r u c t e d n o t to r e p o r t f le e t in g o r m i n o r
d id
s a m p le o f 2 6 4
n o t re p o rt T M D
th e p a s t 6 m o n t h s , w e re a ls o t o r e c e iv e a f i e l d
in t e r v ie w
a n d e x a m in a t io n .
in t e r v ie w ; a n d a s e c o n d w a v e , 1 -y e a r
a c h e s o r p a in s , o r c o n d it io n s
f o llo w - u p
o c c u r r e d o n ly o n a s in g le d a y . F o r e a ch
c o n s e c u t iv e ly b y G H C
p a in c o n d it io n , in f o r m a t io n w a s g a th e re d
T M D , w e r e i d e n t i f i e d f o r in t e r v ie w
A
e x a m in a t io n
a n d in t e r v ie w .
s u b s e q u e n t 3 -y e a r f o llo w u p
is
under
th a t h a d
th e s tu d y . A
A d d i t i o n a l l y , 2 8 9 c l i n i c case s, r e f e r r e d
e x a m in a t io n
fo r tre a tm e n t o f and
b y s t u d y h y g ie n is t s . T h e s e
p e r s o n s w e r e a l s o s e n t s c r e e n in g q u e s t io n n a ir e s ; 83.7% w e r e c o m p le t e d .
SAMPLE
REFERRALS TO
SURVEY
Field examination and interview, wave I. A f ie ld
Al l GHC TMD Re f e r r a l s
GHC En r o l l e e s : Random S ample
N = 289
N = 1265
e x a m in a t io n
a s s e s s in g s i g n s a n d
s y m p to m s o f T M D , in c lu d in g
m a n d ib
u la r r a n g e o f m o t io n , j o in t s o u n d s , p a in o n p a l p a t i o n , a n d p a i n o n f u n c t i o n , as
S c r e e n in g
S c r e e n in g
Qu e s t io n n a ir e
w e l l as d e n t a l, p e r io d o n t a l, a n d o c c lu s a l
Qu e s t io n n a ir e
N = 1016 (80.3%)
v a r ia b le s ,
H = 242 (83.7%)
30% S am ple
a lo n g
is t s w h o s e rv e as f i e l d
Fig 1 ■ Study design: epidem iologic studies of TMD.
Y ES 100% S ample
n a t io n
p ro c e d u re s
in
and
th e e x a m i
c a lib r a t e d
th e v a r ia b le s c o v e r e d b y E x t e n s iv e
th e e x a m
r e lia b ilit y
s t u d ie s
c o m p a r in g th e s e t r a in e d e x a m in e r s w i t h u n c a lib r a t e d c lin ic a l e x p e rts in w e r e c o n d u c t e d 10-11 u s i n g
N=210 (79.6%)
Community Ca s e s
N=121 (88.3%)
Cl i n i c Ca s e s
N=261 (90.3%)
s y m p t o m s b e i n g a sse ssed . E a c h e x a m in e r sa w
e a c h s u b je c t in
in a t io n
N=220 (89.8%)
a b a l a n c e d d e s ig n
th e e ffe c ts o f o r d e r o f e x a m to b e d e t e r m i n e d . R e t r a i n i n g
t o o k p la c e o n th o s e v a r ia b le s f o r w h i c h r e lia b ilit y
N=109 (95.6%)
T M D
s a m p le s o f
s u b je c t s w i t h a n d w i t h o u t th e s ig n s a n d
to a llo w
On e -Y ear Follow Up Exam in a t io n / I n terv iew
to
a c c e p t a b le le v e ls o f r e l i a b i l i t y f o r a sse ss in a t io n .
F i e l d Ex a m in a tio n / I nterv iew
in t e r v ie w e r s a n d
e x a m in e r s w e re t r a in e d
in g
Community Co n tro ls
w it h
p r o c e d u r e s . F o u r r e g is te r e d d e n t a l h y g i e n
Fa c ia l p a i n ?
V
w a s d e v e lo p e d
d e t a i le d s p e c i f i c a t i o n s f o r e x a m i n a t i o n
w a s in it ia lly
in a d e q u a t e a n d
r e l i a b i l i t y w a s re te s te d o n a n e w s a m p le . These
p ro ce d u re s
a p p r o x im a t e ly
w e re
6 -m o n th
re p e a te d
at
in t e r v a ls
t h r o u g h o u t th e s t u d y . F i e l d e x a m i n e r s
274 ■ JADA, Vol. 120, March 1990
CURRENT
CLINICAL
PRACTICE
a c h ie v e d a c c e p t a b le to e x c e lle n t r e l i a b i l i t y
o r p e rc e n t o f o c c u rre n c e fo r e a ch ca te g o ry
ty p e ( t h a t is , C L C A ,
o n a l l v a r ia b le s e x c e p t as n o t e d i n s p e c if ic
is p r o v id e d .
f e m a le s s h o w e d s i g n i f i c a n t l y
w a s d e v e lo p e d a n d p re te s te d to o b t a in in f o r m a t io n
on
u n a s s is t e d
f i e ld in t e r v ie w
Demographic description
m e a su re d in
l o g i c a l fa c t o r s t h a t h a v e b e e n p r o p o s e d
T h e r e w e re n o s t a t is t ic a lly
as p o s s ib le r is k
s ig n if ic a n t
in c is o r s
f a c t o r s o r s e q u e la e o f
d if f e r e n c e s b e t w e e n c a s e ty p e s w i t h r e g a r d
4 to 5 m m
to a g e ( o v e r a ll m e a n a g e = 3 9 y e a rs ) ,
m a x im u m
and
h is t o r y , p s y c h o s o c i a l v a r ia b le s , a n d
e t h n ic it y , o r l i v i n g
m a le s i n
th e C L C A
d id
o f th e T M D p a i n p r o b l e m a m o n g p e r s o n s
fo r
v e r t ic a l o p e n in g ;
w it h T M D .
m a r it a l s ta tu s , a n d g e n d e r. T h e
The
W a v e I F ie ld
and
g r o u p w e r e le s s l i k e l y
g ro u p s
m a le s i n
th e C O C O
i m u m a s s is te d j a w o p e n i n g t h a n f e m a le s
in c o m e s g r e a t e r t h a n $ 3 5 ,0 0 0 ; th e y w e r e a ls o m o r e l i k e l y
and C O C A
s i g n i f i c a n t d if f e r e n c e s i n
to h a v e a tte n d e d
case s a n d c o m m u n it y c o n t r o ls th e s c r e e n in g s u r v e y ,
not show
g r o u p s h o w e d s ig n if ic a n t ly g re a te r m a x
s c h o o l p a s t c o lle g e o r to h a v e h o u s e h o ld
id e n t if ie d t h r o u g h
1). F o r
C LC A
w a s a d m in is t e r e d to th e c o m
I n t e r v ie w m u n it y
E x a m in a t io n
e m p lo y m e n t ,
m a n d ib u la r c e n tr a l
w a s o b s e r v e d ) ( T a b le
t i s t i c a l l y s i g n i f i c a n t d if f e r e n c e s e m e r g e d in c o m e ,
s m a lle r m o t io n ,
a s s is te d o p e n i n g , f e m a le s a n d
s u b je c t ’ s u n d e r s t a n d in g o f th e n a tu r e
e d u c a t io n ,
of
(a g e n d e r d if f e r e n c e o f a b o u t
T M D , a s w e l l as p a i n r e p o r t , t r e a t m e n t
a rra n g e m e n ts. S ta
ra n g e
m illim e t e r s b e tw e e n ed g e s
o f m a x illa r y
p h y s ic a l a n d p s y c h o
th e
v e r t ic a l
CO CO )
to b e u n e m p l o y e d (8%
(P
