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Recognition of Temporomandibular Disorders: validity and outcome of three screening questions (3Q/TMD)
Umeå University, Faculty of Medicine, Department of Odontology, School of Dentistry.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

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.

 

Abstract [sv]

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.

 

Place, publisher, year, edition, pages
Umeå: Umeå University , 2017. , 64 p.
Series
Umeå University odontological dissertations, ISSN 0345-7532 ; 137
Keyword [en]
Temporomandibular disorders, orofacial pain, screening methods, diagnostic accuracy, public health
National Category
Dentistry
Research subject
Odontology
Identifiers
URN: urn:nbn:se:umu:diva-133997ISBN: 978-91-7601-667-1 (print)OAI: oai:DiVA.org:umu-133997DiVA: diva2:1090643
Public defence
2017-05-23, Bergasalen, Norrlands Universitetssjukhus, Södra entrén, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2017-05-02 Created: 2017-04-25 Last updated: 2017-05-02Bibliographically approved
List of papers
1. Temporomandibular pain and jaw dysfunction at different ages covering the lifespan - A population based study
Open this publication in new window or tab >>Temporomandibular pain and jaw dysfunction at different ages covering the lifespan - A population based study
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2016 (English)In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 20, no 4, 532-540 p.Article in journal (Refereed) Published
Abstract [en]

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.

National Category
Dentistry
Identifiers
urn:nbn:se:umu:diva-119269 (URN)10.1002/ejp.755 (DOI)000372516800005 ()26311138 (PubMedID)
Available from: 2016-06-02 Created: 2016-04-15 Last updated: 2017-04-27Bibliographically approved
2. Validity of three screening questions (3Q/TMD) in relation to the DC/TMD
Open this publication in new window or tab >>Validity of three screening questions (3Q/TMD) in relation to the DC/TMD
Show others...
2016 (English)In: Journal of Oral Rehabilitation, ISSN 0305-182X, E-ISSN 1365-2842, Vol. 43, no 10, 729-736 p.Article in journal (Refereed) Published
Abstract [en]

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.

National Category
Dentistry
Identifiers
urn:nbn:se:umu:diva-127275 (URN)10.1111/joor.12428 (DOI)000383570000001 ()27573533 (PubMedID)
Available from: 2016-11-04 Created: 2016-11-04 Last updated: 2017-04-27Bibliographically approved
3. Outcome of three screening questions for temporomandibular disorders (3Q/TMD) on clinical decision-making
Open this publication in new window or tab >>Outcome of three screening questions for temporomandibular disorders (3Q/TMD) on clinical decision-making
Show others...
2017 (English)In: Journal of Oral Rehabilitation, ISSN 0305-182X, E-ISSN 1365-2842, Vol. 44, no 8, 573-579 p.Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
John Wiley & Sons, 2017
Keyword
Temporomandibular Joint Disorders, Facial Pain, Public health dentistry, Decision-making, Clinical Decision Support systems, Health services research
National Category
Dentistry
Identifiers
urn:nbn:se:umu:diva-133996 (URN)10.1111/joor.12518 (DOI)000405237900001 ()28452123 (PubMedID)
Note

Originally published in manuscript form with title: Outcome of three screening questions for temporomandibular disorders (3Q/TMD) on clinical decision-making : Clinical decision making for TMD

Available from: 2017-04-25 Created: 2017-04-25 Last updated: 2017-08-04Bibliographically approved
4. Validity of three screening questions in relation to the DC/TMD in a specialized orofacial pain clinic
Open this publication in new window or tab >>Validity of three screening questions in relation to the DC/TMD in a specialized orofacial pain clinic
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Aims: To determine the validity of three screening questions (3Q/TMD) in relation to the

Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), in a specialized orofacial pain

clinic.

Methods: Consecutive patients, >18 years, referred with a TMD complaint to the Orofacial pain

clinic, Academic Centre for Dentistry Amsterdam, ACTA, the Netherlands, were included in the

study. The study sample, (n=449) with mean age 44 years (72% females) answered the

3Q/TMD and the DC/TMD questionnaire before a clinical DC/TMD examination. The 3Q/TMD

constitutes of two questions on weekly pain from the jaw, face, and temple region, in rest (Q1)

and on function (Q2), and one function-related question on weekly catching and/or locking of the

jaw (Q3). Q1 and Q2 were evaluated in relation to a DC/TMD pain diagnosis and Q3 in relation

to a subgroup of DC/TMD intra-articular diagnosis, referred to as the reference standard.

Results: In total, 44% of patients received a pain-related DC/TMD diagnosis and 33% an

intraarticular reference DC/TMD diagnosis. Sensitivity for the two pain screening questions was

high (0.83-0.94), whereas specificity was low (0.41-0.55). For the function-related question,

sensitivity was low (0.48), whereas specificity was high (0.96).

Conclusions: In most TMD-pain patients, the two pain screening questions are positive. The

high negative predictive values of the two questions on pain (Q1 and Q2) indicate that in

patients with negative responses, the presence of pain-related TMD is quite unlikely. For the

functional screening question (Q3), a positive response is indicative for a subgroup of intra-

articular DC/TMD diagnoses.

Keyword
Temporomandibular disorders (TMD), DC/TMD, validity, screening instrument
National Category
Dentistry
Identifiers
urn:nbn:se:umu:diva-133993 (URN)
Available from: 2017-04-25 Created: 2017-04-25 Last updated: 2017-04-27

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