Background: To easily identify patients who could benefit from a temporomandibular disorder (TMD) examination, three screening questions (3Q/TMD) have been introduced in large parts of Sweden. The questions are related to a TMD diagnosis. However, how the questions relate to a treatment need is unknown.

Objectives: The first aim of the study was to identify predicting factors for perceived treatment need among adult individuals who screened positive to the 3Q/TMD. The second aim was to explore individuals' thoughts and experiences related to treatment of their TMD complaint.

Methods: This mixed‐method study with a case‐control design was conducted in Västerbotten, Sweden, during 2014. Individuals who screened positive to at least one of the 3Q/TMD questions were allocated 3Q‐positives, whereas those with negative answers to all questions were allocated 3Q‐negatives. In total, 300 individuals (140 randomly selected 3Q‐positives, and 160 age‐ and gender‐matched 3Q‐negatives) were included. All individuals answered questions related to treatment need. The answers were analysed in a qualitative approach with qualitative content analysis.

Results: In total, 81% of 3Q‐positives expressed a treatment need related to their TMD symptoms. The perceived treatment need was predicted by frequent pain (Q1) and frequent functional disturbances (Q3). Among the 3Q‐positives, 54% reported mistrust in dentists' ability to treat TMD symptoms. The informants expressed a need for information about their symptoms and possible treatment options.

Conclusion: Affirmative answers to 3Q/TMD were associated with TMD treatment need. Dentists should give advice to patients with TMD symptoms and address their concerns.

Objective: Many patients with temporomandibular disorders (TMD) seem to go undetected within primary dental health care. Primarily we evaluated if the implemented intervention increased the clinical decision-making for TMD patients; secondarily we evaluated if other factors could be identified that predicted performed or recommended TMD treatment.

Material and Methods: This case–control study was carried out within the Public Dental Health service in Västerbotten County, Sweden. An intervention based on a decision-tree with three screening questions for TMD (3Q/TMD) was implemented during 2015 in four clinics and compared with the remaining county. A total of 400 individuals were selected—200 3Q-positives and 200 3Q-negatives. The 3Q/TMD consists of Q1—frequent jaw pain, Q2—frequent pain on function, and Q3—frequent catching and/or locking of jaw. The 3Q/TMD answers were analyzed in relation to TMD treatment and any TMD related decision that was collected from the digital dental records.

Results: The intervention did not increase the frequencies of traceable clinical decisions among patients with TMD.

Conclusions: Despite the implemented intervention aimed, the indicated undertreatment of patients with TMD remains. Future studies are still needed to gain a deeper understanding of the clinical decision-making process for TMD patients in general practice dentistry.

Objective: Pain in the orofacial region may originate from different structures, and one challenge for the clinician is to determine the primary origin of pain reported by the patient. In clinical practice, it is important to discriminate between a temporomandibular joint (TMJ) pain disorder and jaw muscle pain; therefore, tests that are proposed for such purposes warrant evaluation. The aim of the present study was to evaluate the outcome of a TMJ compression test in relation to a Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) arthralgia diagnosis.

Methods: A study population (n = 300), randomly selected from the adult population in Västerbotten, Sweden, was examined according to the DC/TMD criteria and with a TMJ compression test. This test is comprised of forceful unilateral biting for 20 s on a wooden spatula in the first molar region. Familiar pain on the contralateral side to the clenching side was considered a positive test outcome.

Results: Positive contralateral outcome of the TMJ compression test was associated with an arthralgia diagnosis (B = 1.737; OR 5.7, 95% CI 3.3–9.9). This association was confounded by concurrent myalgia (B = 1.737 → B = 0.996, 42.7%).

Conclusion: In a general population, a negative TMJ compression test was strongly associated with the absence of a contralateral TMJ arthralgia diagnosis according to DC/TMD. The association between a positive TMJ compression test and a DC/TMD arthralgia diagnosis was confounded by the presence of myalgia.

Clinical relevance: Concurrent myalgia renders the usefulness of the TMJ compression test for predicting an arthralgia diagnosis questionable.

OBJECTIVE: Dental students have been identified as a group with high risks of developing both temporomandibular disorders (TMD) and psychosocial conditions. Our primary aim was to evaluate the cross-sectional prevalence of TMD diagnoses, as defined in the Diagnostic Criteria (DC)/TMD, among dental students. The secondary aim was to evaluate the prevalence and association of behavioural and psychosocial factors in relation to DC/TMD diagnoses.

MATERIALS AND METHODS: The study was conducted among undergraduate dental students during the second semester of their third year at the Department of Odontology, Medical Faculty, Umeå University, Sweden. Three consecutive cohorts were recruited during August in 2013, 2014, 2015. In total, 54 students were included and examined according the DC/TMD procedure.

RESULTS AND CONCLUSIONS: The prevalence of any DC/TMD diagnosis was 30%. The most prevalent TMD diagnosis was myalgia. Individuals with a TMD-pain diagnosis (i.e. myalgia or arthralgia) reported significantly higher pain intensity levels according to the Graded Chronic Pain Scale (GCPS) as compared to individuals without TMD-pain (Fisher's exact test p < .001, two-sided). In addition, individuals with any TMD scored significantly higher jaw functional limitations according to the Jaw Functional Limitation Scale 20 (JFLS-20, p < .001) and oral parafunctions according to the Oral Behavior Checklist (OBC, p = .005) as compared to individuals without TMD. The psychosocial factors evaluated did not differ between individual with or without a TMD diagnosis. The majority of the dental students reported symptoms that are already identified as risk factors for developing TMD and pain conditions. However, longitudinal data are needed to evaluate how this evolves over time.

Temporomandibular disorders (TMDs) are common, but many patients with such disorders go undetected and under-treated. Our aim was to evaluate the outcome of using a screening tool (5 yr after it was first implemented), on the clinical decision-making for patients with TMDs. Adults who attended for a dental check-up at the Public Dental Health Services in Västerbotten, Sweden, answered three screening questions (3Q/TMD) on frequent jaw pain, pain on jaw function, and catching/locking of the jaw. The dental records of a random sample of 200 individuals with at least one positive response to 3Q/TMD (3Q screen-positive patients) and 200 individuals with all negative responses (3Q screen-negative patients) were reviewed for TMD-related treatment decisions. A clinical decision related to TMD was absent in 45.5% of 3Q screen-positive patients. Treatment of TMDs was associated with a positive response to the screening question on jaw pain (OR = 6.7, 95% CI: 3.2-14.0) and was more frequent among 3Q screen-positive patients (24%) than among 3Q screen-negative patients (2%; OR = 15.5, 95% CI: 5.5-43.9), just as a female examiner was associated with more frequent treatment of TMDs (OR = 3.1, 95% CI: 1.2-8.4). The results indicate under-treatment of TMD within general dental practice and that male clinicians are less likely to initiate TMD treatment.

Patients with temporomandibular disorders (TMD) seem to go undetected and not adequately managed within dentistry. To identify these patients, three screening questions (3Q/TMD) have been introduced within dentistry in parts of Sweden. It is not known whether 3Q/TMD affects the clinical decision-making for these patients. The aim of this study was to evaluate the outcome of 3Q/TMD on the clinical decision-making and to analyse whether gender, age and the fee system the individual was assigned to were related to prescribed TMD treatment. This cohort study was carried out within the Public Dental Health service in Vasterbotten, Sweden. As part of the routine dental check-up, a health declaration including 3Q/TMD was completed. The study population was randomly selected based on their 3Q/TMD answers. In total, 300 individuals with an affirmative answer to any of the 3Q/TMD, and 500 individuals with all negative answers were selected. The 3Q/TMD includes questions on weekly jaw-face-temple pain (Q1), pain on function (Q2) and catching/locking of the jaw (Q3). The 3Q/TMD was analysed in relation to prescribed treatment assessed from dental records. There was significantly more treatment performed or recommended for 3Q-positives (215%), compared to 3Q-negatives (22%) (P < 0001). The odds ratio for TMD-related treatment for 3Q-positives versus 3Q-negatives was 121 (95% CI: 63-234). Although affirmative answers to the 3Q/TMD was related to TMD treatment, the majority of individuals with a screen positive still did not, according to dental records, receive assessment or treatment. Further studies are needed to better understand the clinical decision-making process for patients with TMD.

Background

Pain and dysfunction in the temporomandibular region (Temporomandibular Disorders, TMD) are common conditions in the general population with an estimated treatment need of 5-15% in the general population. However, in Sweden, traceable performed treatments are significantly lower. The reasons for this indicated under-treatment are not known. To easily detect patients with a potential TMD related condition, three screening questions, 3Q/TMD, have been introduced. The aim with this project was to evaluate the validity and outcome of the 3Q/TMD with the objective to recognize individuals with TMD and potential treatment need in the Public Dental Health service (PDHS).

Methods

The thesis is based on four study samples; three from the PDHS in the county of Västerbotten, Sweden and one sample from the specialized orofacial pain clinic at the Academic Centre for Dentistry, ACTA, Amsterdam, the Netherlands. The bases for all studies are individuals’ answers to the 3Q/TMD and quantitative approaches were used in the analyses. The prevalence of affirmative answers was evaluated in a large cross-sectional study over the lifespan. The validity of the 3Q/TMD in relation to the Diagnostic Criteria for TMD (DC/TMD) as reference standard was established in two case-control studies. The outcome of the 3Q/TMD on TMD treatment within general practice was evaluated in a cohort study.

Results

Affirmative answers to the 3Q/TMD increased during adolescence. Women answered affirmatively to the 3Q/TMD significantly more often compared to men for all age groups expect for the first and last parts of a one hundred-year lifespan. The highest prevalence was reported by women during their fertile period in life. In a general population sample, 74% of individuals with an affirmative answer qualified for a DC/TMD pain or dysfunctional diagnosis, as compared to 64% in a specialist patient sample. In the general population sample, for the individual 3Q/TMD questions, as well as combinations of questions, the negative predictive values were high (0.92-0.99). For the specialist sample, when at least one question was answered affirmatively the negative predictive value was high (0.90). The positive predictive value was high (0.89) when all three questions were positive. There was significantly more treatment performed or recommended for 3Q-positives (21.5%) compared to 3Q-negatives (2.2%) (P<0.001). The odds ratio for TMD-related treatment for 3Q-positives versus 3Q-negatives was 12.1 (95% CI: 6.3-23.4).

Conclusion

The 3Q/TMD is a convenient and valid tool to recognize individuals who would benefit from a further TMD examination within an adult, general population. Within specialized orofacial pain clinics, the questions are useful as guidance for further diagnostics. Although the 3Q/TMD was a factor related to TMD treatment, the majority of individuals with self-reported symptoms of TMD still did not receive traceable assessment or treatment. Factors associated with dentists’ clinical decision-making in relation to TMD warrants further research. The utilization of the 3Q/TMD as a part of a decision tree for the clinician can improve the health care for patients with TMD and is therefore recommended within dentistry.

Bakgrund

Smärta och funktionsstörningar i käksystemet (TMD) är vanligt förekommande och de flesta av dessa patienter kan behandlas framgångsrikt i tandvården. Tidigare studier har visat att det kan finnas en skillnad mellan det skattade vårdbehovet och utförd behandling för patienter med TMD i tandvården. Anledningen till detta är inte känt och har identifierats som en kunskapslucka av Socialstyrelsen. Den vanligaste orsaken till akut smärta i ansiktsregion är tandvärk medan kronisk smärta oftast är relaterat till smärttillstånd i muskulatur och käkled (TMD). Att leva med smärta har en negativ påverkan på livskvaliteten oavsett om smärtan är orsakad av tandvärk eller TMD. Kvinnor uppger symtom på TMD ungefär två gånger så ofta som män och förekomsten är som högst bland kvinnor i arbetsför ålder. Smärtan är ofta relaterad till stress och långvarig smärta ökar risken för såväl spridning till andra lokalisationer som till sömnbesvär och nedstämdhet. Tidig intervention har visat sig betydelsefull för att minska risken för negativa konsekvenser relaterat till kroniska besvär. Sammantaget visar detta på vikten av ett system inom tandvården för att tidigt identifiera patienter som är i möjligt behov av fördjupad utredning och eventuellt behandling. Därför har tre screeningfrågor för TMD, 3Q/TMD införts inom tandvården. I Folktandvården i Västerbotten infördes frågorna i maj 2010 som en obligatorisk del av den digitala hälsodeklarationen för samtliga patienter.

Syfte

Syftet med avhandlingen har varit att synliggöra patienter med smärta och käkfunktionsstörning i befolkningen och att därmed förbättra omhändertagandet av patienter med TMD inom Folktandvården. De specifika målen var att:

i) beskriva förekomst av frekvent smärta och dysfunktion i ansikte, käke och käkled för män och kvinnor för olika åldersgrupper baserat på tre screeningfrågor ii) bedöma de tre screeningfrågornas validitet i förhållande till en diagnos enligt Diagnostic Criteria for TMD, DC/TMD i två olika populationer iii) utvärdera utfallet av 3Q/TMD på klinisk beslutsprocess inom Folktandvården i Västerbotten, Sverige.

Studiepopulation och metod

Avhandlingen baserades på fyra olika urval av patientpopulationer, tre från Folktandvården i Västerbotten, Sverige och en från Specialistkliniken från Academish Centrum Tandheelkunde Amsterdam, ACTA, Amsterdam, Nederländerna. Underlaget för samtliga studier var baserade på individuella svar på de tre screeningfrågorna. Förekomsten av de som svarat ja på någon av frågorna utvärderades i en tvärsnittsstudie bland nästan 140 000 individer och över ett helt livsspann. Validiteten för 3Q/TMD i relation till en diagnos enligt DC/TMD utvärderades i två fall-kontroll studier. Först undersöktes en studiepopulation från Folktandvården i Västerbotten, Sverige för att representera allmän befolkningen. Därefter utvärderades screeningfrågorna bland de patienter som remitterats till en specialistklinik i Amsterdam, Nederländerna på grund av TMD relaterade besvär. Dessa representerar remitterade patienter. Utfallet av 3Q/TMD på TMD behandling i Folktandvården utvärderades i en prospektiv kohort studie.

Resultat

Förekomsten av de som svarat ja på någon av frågorna ökar under tonåren. Kvinnor svarar ja på någon av frågorna signifikant oftare än män i alla åldrar, utom i början och slutet av livsspannet. Den högsta prevalensen noterades för kvinnor i fertil ålder. I allmänbefolkningen kvalificerar 74% av de som svarat ja på någon av frågorna även för en DC/TMD diagnos. Motsvarande siffra för urvalet från specialistkliniken var 64%. I urvalet från allmänbefolkningen var det negativa prediktiva värdet högt för såväl alla enskilda frågor som för kombinationer av frågor (0.92-0.99). Bland de remitterade patienterna, var negativt prediktivt värde högt när individen svarade ja på minst en fråga (0.90). Positivt prediktivt värde var högt när individen svarat ja på alla tre frågorna (0.89). Behandling hade utförts eller rekommenderats signifikant oftare till de som svarat ja på någon av frågorna (21.5%) jämfört med de som svarat nej på alla tre frågor (2.2%) (P<0.001). Odds ratio för TMD behandling för 3Q-positiva jämfört med 3Q-negativa var 12.1 (95% CI:6.3-23.4).

Slutsats

Sammanfattningsvis visar resultaten att en betydande andel av befolkningen, framför allt kvinnor i arbetsför ålder, har smärta och/eller funktionsstörningar i käksystemet. Frågorna är lämpliga för att screena patienter i behov av en fördjupad utredning. De som svarat nej kommer med stor sannolikhet inte att kvalificera för en diagnos enligt DC/TMD. Bland remitterade patienter kommer majoriteten att svara ja på någon av frågorna. I allmäntandvården får två tredjedelar av det som svarat ja på minst en fråga, inte ett synliggjort omhändertagande baserat på vad som är angivet i deras tandvårdsjournal. Detta kan tyda på brister bland allmäntandläkare och tandhygienister i kliniskt beslutsfattande för patienter med TMD.

Background

Temporomandibular pain and jaw dysfunction can have a negative effect on daily life, but these conditions are not well recognized in the health care systems. The general aim was to examine the cross-sectional prevalence of frequent temporomandibular pain and jaw dysfunction in men and women across the lifespan.

Methods

The analysis was based on data from 137,718 individuals (mean age 35years, SD 22.7) who answered three questions (3Q/TMD) included in the digital health declaration in the Public Dental Health care in the county of Vasterbotten, Sweden; Q1: Do you have pain in your temple, face, jaw or jaw joint once a week or more?'; Q2: Does it hurt once a week or more when you open your mouth or chew?'; and Q3: Does your jaw lock or become stuck once a week or more?'

Results

The prevalence of frequent temporomandibular pain (Q1) was 5.2% among women and 1.8% among men (p<0.0001). The prevalence of frequent pain on jaw movement (Q2) was 2.5% among women and 0.9% among men (p<0.0001). The prevalence of frequent locking of the jaw (Q3) was 2.7% among women and 1.2% among men (p<0.0001).

Conclusions

The study shows that the cross-sectional prevalence of temporomandibular pain and jaw dysfunction varies during the lifespan. For men and women, respectively, symptoms increase during adolescence, peak in middle age and then gradually diminish. The prevalence of these symptoms is significantly higher among women except from the first and last decades of a 100-year lifespan.

Temporomandibular disorders (TMD) are common but seem to be largely undetected within general dental care. To improve dentists' awareness of these symptoms, three screening questions (3Q/TMD) have been introduced. Our aim was to validate 3Q/TMD in relation to the diagnostic criteria for TMD (DC/TMD), while taking into account the severity level of the symptoms. The study population consisted of 7831 individuals 20-69 years old, who had their routine dental check-up at the Public Dental Health Service in Västerbotten, Sweden. All patients answered a health declaration, including the 3Q/TMD regarding frequent temporomandibular pain, pain on movement and catching/locking of the jaw. All 3Q-positives (at least one affirmative) were invited for examination in randomised order. For each 3Q-positive, a matched 3Q-negative was invited. In total, 152 3Q-positives and 148 3Q-negatives participated. At examination, participants answered 3Q/TMD a second time, before they were examined and diagnosed according to DC/TMD. To determine symptom's severity, the Graded Chronic Pain Scale and Jaw Functional Limitation Scale-20 (JFLS-20) were used. In total, 74% of 3Q-positives and 16% of 3Q-negatives met the criteria for DC/TMD pain or dysfunction (disc displacements with reduction and degenerative joint disorder were excluded). Fifty-five per cent of 3Q-positives had a TMD diagnosis and CPI score ≥3 or a JFLS-20 score ≥5, compared to 4% of 3Q-negatives. The results show that the 3Q/TMD is an applicable, cost-effective and valid tool for screening a general adult population to recognise patients in need of further TMD examination and management.