Portuguese Version

Year:  2001  Vol. 67   Ed. 6 - (2º)

Artigo Original

Pages: 763 to 768

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The sensibility appreciation of the questionnaire for selection of orofacial pain and temporomandibular disorders recommended by the American Academy of Orofacial Pain

Author(s): Ana Paula S. Manfredi 1,
Ariovaldo A. Da Silva 2,
Laércio L. Vendite 3

Keywords: TMJ disorders, orofacial pain, ear symptoms, questionnaire, migraine

Abstract:
Introduction: The Temporomandibular Joint Disorders (TMJ Disorders) has very ample interpretation and describes a population of patients suffering from muscles dysfunctions and the muscles and toggles of jaw usually painful 1. Beyond the complaints of pain in the cheek, ear pain and migraines the patients with these clutters many times have limited or anti-symmetrical jaw movements, and the sounds of the TMJ most described as "clicks". Aim: With intention to make qualitative and quantitative analysis of the use and acuracity of an instrument of diagnostic aid, we used the "Questionnaire for Selection for Orofacial Pain and TMJ Disorders", recommended for the American Academy of Orofacial Pain (attachment 1), not yet tested in Brazil. The target population was made of patients with complaints of dental pain in the orofacial region, chronic headache, ear ache and daily pain in the preauricular area or in the TMJ, that made they seek for medical and dental attention at the CSS/CECOM, an ambulatory that the Unicamp keeps for the attendance of its internal community. Study design: Prospective clinical randomized. Method: The questionnaire was applied to 46 patients (40 women and 6 men), with later a specific clinical examination that resulted diagnosis of TMJ Disorders. Results: The statistical analysis disclosed that this questionnaire presents a sensitivity of 85,37% and a specificity of 80% for carrying patients of muscular symptoms of the orofacial region (Kappa = 0.454) and a low sensitivity and specificity for articulate symptoms (Kappa = 0.043). Conclusion: The questionnaire is useful and viable for a daily selection of TMJ Disorders, mainly for the myogenic riots, but shouldn't be use as the only tool for diagnosis.

Introduction

Temporomandibular disorders (TMD), also called craniomandibular disorders, comprise a group of diseases that affect not only the temporomandibular joint (TMJ), but also the extrinsic areas of the joints9.

TMD were identified as the main cause of non-dental pain on the orofacial region1, 10. The painful system is generally located on mastication muscles, pre-auricular areas and/or TMJ 1, considered a subcategory of muscle-skeletal disorders16.

TMD have a wide range of interpretations and describe a general population who suffers from mandible muscle and joint dysfunctions, which are usually painful. It is not a homogenous group of patients, because different etiologies and pain mechanisms are responsible for similar manifestations. It is essential to diagnose the specific cause in order to treat effectively the patient.

Pain described as facial, on the jaws, pre-auricular, earache and headache are commonly aggravated by mandibular function, known as extra-capsular disorders. Deviations from mandibular movements, limited or asymmetric mandibular movements may be a result of muscle hyperactivity responsible for the closure of the mandible, but it may also be the result of intra-capsular disorders. In such cases, TMJ clicking and/or noises are the most frequent signs.

The most frequent sign of extra-capsular or myogenic disorders is diffuse facial pain. Historically, excessive muscle activity was considered the cause of fatigue, leading to pain. Studies have shown that in normal (non-patient) subjects when the teeth are voluntarily tightened5, 6 or mandibular protrusion is forced18, there is acute pain. In addition, Christensen4 reported that grinding the teeth and lateral mandibular movements involved elongation of masseter and medial pterygoid muscles while they were contracting. The signs produced when the masseter muscle is involved are described as "pain in the mandible". If there is further involvement of the temporal muscle, there is complaint of headache. The signs of otalgia and retrobulbar pain indicate higher sensitivity of the lateral pterygoid muscle. Pain on the mandibular angle upon mastication, as well as odynophagia, stemmed from the medial pterygoid.

Internal or intra-capsular disorders are all the abnormal processes that occur in the limits of the TMJ, including not only disk displacement, but also osteoarthrosis, inflammatory arthritis, congenital deformities and traumatic, neoplastic and developmental abnormalities13.

Evaluating these patients require careful multidisciplinary analysis. To detect in the anamnesis the possibility of TMD directs the remaining procedure. The correct use of clinical approach of the patient with facial pain enables appropriate treatment intervention. Based on our observation that physicians and dentists face difficulties when treating orofacial pain, the use of a specific anamnesis may facilitate this task, guiding clinical investigation and speeding up diagnosis and therapy.

OBJECTIVE

The main purpose of the present study was to evaluate the degree of sensitivity and specificity of the Screening Questionnaire for Orofacial Pain and TMD recommended by the American Academy of Orofacial Pain (Annex 1), which had not been tested in Brazil yet. We also wanted to correlate the findings with the specific odontological examination for TMD diagnosis.

MATERIAL AND METHOD

We selected a sample from patients treated in the Ambulatory of Medicine and Dentistry (CSS/CECOM) of Universidade Estadual de Campinas, directed to treating its internal clients.

We analyzed a total of 46 patients (40 women and 6 men), mean age of 31 years, who had spontaneously come to the ambulatory between January and August 2000. The patients had already been evaluated by other healthcare providers and still maintained complaints of headache, pain on orofacial region, clicks on the auricular and pre-auricular regions, but they did not have clinical signs to justify migraine, ear pathologies or any other inflammatory or infectious process from dental origin.

Patients were initially submitted to medical assessment and the complaints of headache, auricular and pre-auricular pain, and orofacial pain were not positive to neurological or otorhinolaryngological signs; thus, patients were referred to odontological investigation.

In the ambulatory, patients answered a screening self-explanatory questionnaire recommended by the American Academy of Orofacial Pain and TMD (Annex 1). The questionnaire comprised 10 directed yes/no questions, including the most frequent signs and symptoms of orofacial pain and TMD (Graph 1).

A precise clinical examination, pantographic x-ray and informed consent term from the Research Ethics Committee of the Medical School, Universidade Estadual de Campinas, were collected.

In the clinical odontological examination, the following items were analyzed:

· main complaint;
· presence of systemic disease (no patients with systemic diseases were included in the study);
· maximum mouth opening, based on the normal range of 40-45mm;
· TMJ clicks when opening and closing the mouth, through bilateral digital palpation;
· presence of teeth wear, indicating possible parafunction, such as bruxism;
· reference to manifestations of stress;
· history of microtrauma on the orofacial region, specially "whiplash";
· previous orthodontic treatment;
· palpation of the mastication and retrocondylar muscles.

The assessment of the painful muscle condition upon palpation was conducted by one single examiner in the first visit, and pain classification was scored as follows:

0 no pain;
1 mild pain;
2 medium pain;
3 severe pain.

The muscles evaluated were: medial pterygoid, masseter, temporal (mandible elevators), mylohyoid and sternocleidomastoid, and the retrocondylar region when the patient had the mouth opened. We also checked dental trauma, dental occlusion, previous orthodontic treatment and local and cervical trauma.

Pantographic or panoramic x-ray was ordered to support diagnosis of chronic or subacute infectious condition from dental origin, and to rule out the hypothesis of cysts or neoplasias.

Results

The descriptive analysis of tables and frequencies and position and dispersion measures of the questionnaire and clinical examination showed that:

Questions 1 and 2 of the questionnaire, related to movement of mouth opening and closure: since perception of patients concerning normal pattern of this movement varies from subject to subject, the item was verified in the clinical assessment and although there has been 52.2% and 39.1% of positive responses for questions 1 and 2, respectively, the maximum mean mouth opening of patients was 49mm.

Questions 3 and 5 were directed to typical TMD painful signs, such as difficulty and/or pain upon mastication and speech, and fatigue in the jaws5, 6, which characterized these two questions as the most important ones in the questionnaire. The signs are related to inappropriate use of stomatognathic system that serves as the occlusion pattern of the patient, together with habits such as tightening and/or clenching teeth. For this reason, the percentage of positive responses was 60.9% and 67.4%, respectively, and the correlation with clinical examination was significant (kappa = 0.449).

Question 4 asked about the presence of noises in the TMJ 7, and there were 67.4% of positive responses and only 30.4% of the subjects confirmed the presence of intra-capsular click in the clinical assessment.

Questions 6 and 7 listed the main symptoms of orofacial pain and extra-capsular disorders of TMJ, which are: pain around the ears (47.8% of negative answers and 52.2% of positive answers), temporal region (52.2% of negative answers and 47.8% of positive answers), or cheeks (82.6% of negative answers and 17.4% of positive answers); headaches (43.5% of negative answers and 56.5% of positive answers); pain on the neck (50.0% of negative answers and 50.0% of positive answers), and on the teeth (63.0% of negative answers and 37.0% of positive answers).

The main objective of question 8 was to investigate the presence of macrotrauma, such as falls, car accidents, direct trauma on the mandibles and maxillas or the cranial-cervical region16, in an attempt to relate them to the main complaint of the patient. In the sample, the percentage of patients that had suffered a recent head trauma was only 6.5%.

In question 9, the perception of the patient towards his or her dental status was relevant because it is an indication that the signs of the main complaint may be related to the mastication system; the percentage of positive answers was 19.6% and of negative answers was 80.4%.

Question 10 informed whether the patient has already been through any odontological treatment for TMJ problems.

In the clinical assessment, items responsible for dental wear, resulting from parafunction, such as bruxism and stress, were the positive etiological factors most frequently found in the clinical examination (Graph 2).

The muscles that presented the highest frequency of pain - score 2 (medium pain) and 3 (severe pain) and highest percentage of affected patients were medial pterygoid and sternocleidomastoid (Graphs 3 and 4).

Graph 1.



Graph 2.



Graph 3.



Graph 4.

Discussion

The TMD-directed and specific clinical assessment reinforced some of the most frequent potential etiological factors in this sample, among which we can mention dental wear. Dental occlusion is still considered one of the predisposing factors to the onset of temporomandibular disorders6, since unstable dental occlusion may lead to mastication muscle unbalance, overloading one mastication side. If the patient wears dental prosthesis, wear of artificial teeth can result in reduction of normal height of the inferior facial third, causing damage to the TMJ. The correlation occlusion-temporomandibular disorder was stronger in the past11, and orthodontics was the only treatment approach for orofacial pain; however, recent studies showed that, in some occasions, patients developed bruxism and pain as a result of the change in dental occlusion16.

Upon muscle palpation we noticed that sternocleidomastoid muscle was sensitive to palpation producing pain scores of 2 (medium pain) and 3 (severe pain) in 41.3% and 21.7%, respectively.

Sternocleidomastoid muscle, which has sensitive innervation from the second and third cervical nerves, is not a muscle directly related to mastication and painful palpation was the result of nervous impulses from the 5th cranial nerve (trigeminal), from periodontal and lingual tissues, TMJ and muscle receptors that may influence the branches of muscle motoneurons. Trigeminal impulses should be considered because of the relation between descending pathways of the trigeminal nerve and upper cervical roots. Neurons of the three divisions of the trigeminal nerve and cranial nerves 7th, 9th and 10th share the same neuronal bundles that come from the primary cervical segments18.

To check the agreement between questionnaire assessment and clinical examination we used Kappa's coefficient8,9. The interpretation of the magnitude of the coefficient is defined as: values equal or greater than 0.75 indicate excellent agreement, values between 0.75 and 0.40 indicate good agreement and values equal or lower than 0.40 do not indicate agreement.

Statistical analysis checked the positive and negative answers found in the questionnaire, correlated with the clinical findings of the specific TMD anamnesis. We performed a number of correlations among the most indicative questions of the potential etiology of TMD. The data we found were:

1 Positive answers to question 1 or 2 and maximum mouth opening of 40mm - Kappa = 0.090. The difficulty to open the mouth could imply the existence of an intra-capsular disorder (lack of coordination condyle-disk, or closed-lock, in which the capsular disk is placed in front of the mandibular condyle, which is not recovered during mouth opening)7. However, it was not noticed in any subject in our sample. This finding confirms the model proposed by Lund et al. in which pain causes the limitation of mandibular movements in two different ways:

· because of voluntary restriction of movement up to a free pain level;
· by reflex activation of the antagonist muscles during the movement, in which both amplitude and speed of movements are reduced.

2 Positive answer to question 3 with pain scores 2 and 3 for medial pterygoid muscle - Kappa = 0.449, but other muscles correlated independently to specific questions, such as questions 6 and 7, did not present a significant correlation. We decided to associated questions 3 and 5 with the mandibular elevation muscles (medial pterygoid, masseter and temporal) and the result was significant (Kappa = 0.454). Sensitivity of the questionnaire to this type of pain assessment was 85.37% and the specificity was 80.00%.

3 Positive answer to question 4 and presence of TMJ click when opening and closing the mouth - Kappa = 0.043. This finding was very interesting because 31 patients reported TMJ clicks but this finding was not confirmed by the clinical examination. Intra-capsular click, or reduction condyle-disk lack of coordination, takes place when the capsular disk is wrongly positioned in from of the mandibular condyle, but it is corrected once we open the mouth and restore the appropriate position12. An electromyography and arthrography study in patients with mandibular clicks and normal patients, by Zijun; Huiyon & Weiya (1989)14, concluded that medial and lateral pterygoid muscle hyperfunction in patients with normal arthrography may produce mandibular movements that are different from characteristic clicks of intra-capsular disorders, although this mechanism of muscle hyperfunction may contribute to the development of the pathology.

Conclusion

· The questionnaire is sensitive and correlated to extra-capsular pathologies or myogenic disorders in which the main complaint is diffuse and radiated facial pain.
· It does not define presence and severity of intra-capsular pathologies.
· It indicates the need for multidisciplinary assessment for patients with headaches, facial pain, pain on the auricular and pre-auricular regions and joint clicks.


References

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1 Dentist, Post-Graduation under course, Department of Otorhinolaryngology, FCM - Unicamp
2 Ph.D., Professor of the Discipline of Otorhinolaryngology, FCM - Unicamp
3 Full Professor in Biomathematics, Department of Applied Mathematics, IMECC - Unicamp

Study conducted at the Ambulatory of Dentistry CSS/Cecom, Unicamp
Address correspondence to: C.D. Ana Paula Sereni Manfredi - Av. Andrade Neves 707, conj. 301 - 13013-161 - Campinas/ SP - manfredi@correionet.com.br
Article submitted on May 10, 2001. Article accepted on July 20, 2001.

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