Objective: To assess the prevalence of clinical signs and pain symptoms of temporomandibular disorders (TMD) and associated factors in the Finnish adult population, as well as the association between self-reported TMD pain symptoms and clinical signs.Material and methods: The sample consisted of 1577 Finnish adults who participated in the Health 2011 Survey (BRIF8901). Signs of TMD were assessed using clinical examination, and TMD pain symptoms were inquired using validated questions.Results: Of the study subjects, 35% showed at least one sign of TMD, 8% reported weekly facial pain and 6% weekly pain when biting or jaw opening. According to logistic regression, female gender, poor general health and low level of education increased the risk for most TMD signs and TMD pain symptoms. Muscle or TMJ pain on palpation associated significantly with self-reported weekly facial pain or pain when biting or jaw opening.Conclusion: Over a third of the population showed clinical signs of TMD and less than one-tenth reported TMD pain symptoms. An assessment of a patient's general health needs to be a part of TMD diagnosis and treatment. The Finnish versions of the validated questions are applicable for screening of TMD pain.

Aims: To investigate whether an international consensus exists among TMD experts regarding indications, performance, follow-up, and effectiveness of jaw exercises. Methods: A questionnaire with 31 statements regarding jaw exercises was constructed. Fourteen international experts with some geographic dispersion were asked to participate in this Delphi study, and all accepted. The experts were asked to respond to the statements according to a 5-item verbal Likert scale that ranged from 'strongly agree' to 'strongly disagree." The experts could also leave free-text comments, which was encouraged. After the first round, the experts received a compilation of the other experts' earlier responses. Some statements were then rephrased and divided to clarify the essence of the statement. Subsequently, the experts were then asked to answer the questionnaire (32 statements) again for the second round. Consensus was set to 80% agreement or disagreement. Results: There is consensus among TMD experts that jaw exercises are effective and can be recommended to patients with myalgia in the jaw muscles, restricted mouth opening capacity due to hyperactivity in the jaw closing muscles, and disc displacement without reduction. The patients should always be instructed in an individualized jaw exercise program and also receive both verbal advice and written information about the treatment modality. Conclusion: This Delphi study showed that there is an international consensus among TMD experts that jaw exercises are an effective treatment and can be recommended to patients with TMD pain and disturbed jaw function.

Recently, updated diagnostic criteria for temporomandibular disorders (DC/TMD) were published to assess TMD in a standardised way in clinical and research settings. The DC/TMD protocol has been translated into Finnish using specific cultural equivalency procedures. To assess the interexaminer reliability using the Finnish translations of the DC/TMD-FIN Axis I clinical diagnostic assessment instruments. Reliability assessment data were collected during a 1-day DC/TMD Examiner Training Course at the University of Turku, Finland, in collaboration with the International DC/TMD Training and Calibration Center in Malmö University. Clinical TMD examinations according to the Finnish pre-final version of the DC/TMD Axis I assessment protocol were performed by four experienced TMD specialists on altogether 16 models. Kappa coefficient, overall percentage agreement (%A) as well as positive (PA) and negative (NA) agreements were used to define the reliability. Myofascial pain with referral, headache attributed to TMD and disc displacement (DD) without reduction without limited opening showed excellent kappa values (range 0·87-1·00). Fair-to-good reliability was observed for diagnoses of myalgia (k = 0·67), arthralgia (k = 0·71) and DD with reduction (k = 0·64). The PA was high for all pain-related diagnoses and DD without reduction without limited opening (medians ≥83%), and acceptable for DD with reduction (median 67%). The NA was high (medians ≥87%) for all DC/TMD diagnoses, except for myalgia which showed acceptable NA (median 75%). The %A was high for all assessed diagnoses (medians >85%). The findings of this study showed DC/TMD-FIN Axis I to demonstrate sufficiently high reliability for pain-related TMD diagnoses.

Objective: To study the outcome of oral appliance treatment in myofascial Temporomandibular disorder (TMD) patients with and without comorbid pain using pain site drawings. Material and methods: This randomized, controlled multicentre study comprised 65 myofascial TMD patients diagnosed according to the Research Diagnostic Criteria for Temporomandibular Disorders. Pain-site drawings were filled in at the baseline examination. The patients were treated with oral appliances. Treatment outcome was followed up for 1 year and analysed according to the recommendations by the Initiative on Methods, Measurement and Pain assessment in Clinical Trials (IMMPACT) on an intent-to-treat basis. The data were analysed for two pain profiles, localized pain (face and head, n = 26) versus widespread pain group (pain sites outside the face and head, n = 39). Results: Statistically significant improvement was registered within both groups for all outcome variables (characteristic pain intensity, 30% pain reduction of worst reported pain, graded chronic pain, depression, and somatization scores) during the follow-up with only small differences between the groups. Conclusions: Oral appliance treatment had a positive effect on all outcome measures during the 1-year follow-up in patients suffering from myofascial TMD pain, regardless of whether the pain was localized or widespread. Multiple pain sites seemed to have surprisingly little influence on the outcome variables. However, some indications of more challenges when treating patients with widespread pain compared to local pain could be observed. Pain-site drawings seem to be useful in the clinical situation and could support the clinicians in decision-making regarding treatment planning.

AIMS:To assess drawings of pain sites and self-reported comorbid pains as a part of the biopsychosocial profiling of tertiary care referral patients with temporomandibular disorder (TMD) pain.METHODS:A total of 135 consecutive patients referred to tertiary care for TMD pain participated. Patients drew all the sites where they had pain on whole-body pain drawings. Other assessments included self-reported comorbid pains in the head and body regions, the Finnish Research Diagnostic Criteria for TMD (RDC/TMD_FIN Axis II), and additional biopsychosocial and treatment-related variables. Patients were grouped into pain drawing profiles (localized, regional, and widespread) and the associations between these profiles and the biopsychosocial variables were statistically evaluated using Bonferroni adjusted P values and with logistic regression using SAS 9.3.RESULTS:A total of 21% of the patients reported localized TMD pain, 20% reported regional pain (headaches and neckaches), and the majority, 59%, reported widespread pain (local/regional and multiple bodily pain sites). Patients with widespread pain profiles formed a heterogenous group in which 28.2% reported severe and 30.8% reported moderate pain-related disability. The widespread pain patients reported significantly higher levels of depression and somatization, lower levels of general health, more sleep dysfunction, decreased ability to control pain, and greater health care needs compared to patients with localized pain (P < .05). Patients with regional pain profiles reported moderate scores on psychosocial functioning compared to the patients with localized or widespread pain.CONCLUSION:The majority of tertiary care referral patients with TMD pain reported comorbid pains. Pain drawings were found a useful adjunctive tool for screening and as a part of comprehensive biopsychosocial assessment and treatment planning for patients with TMD pain.

The idea of this article is to summarize the information in the other articles in this series, to provide a hands-on check-list approach to diagnosis of the most common chronic orofacial pain conditions.This article therefore covers chronic orofacial pain, risk factors, diagnosis of the most common musculoskeletal and neuropathic pain conditions in the orofacial region and management principles.he purpose of this article is to provide efficient checklists to be used in general practice to assess and evaluate as well as for initial management decisions of the most common chronic musculoskeletal or neuropathic pain conditions in the orofacial area.However, this chapter does not cover acute pain.For in-depth explanations of the conditions and managements, please see the other chapters in this series.

Det ar viktigt att ha ett praktiskt material tillgangligt for diagnostik och behandling av patienter med kroniska orofaciala smartor. Denna artikel innehaller en checklista for diagnostik av de vanligaste smarttillstanden. Konservativa reversibla behandlingsmetoder ar minst lika effektiva som invasiva behandlingar och innebar langt mindre risk for att skada patienten, sa de bor vara forstahandsalternativ for de allra flesta patienter med kroniska orofaciala smartor.

AIMS:To use the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis II and additional pain-related and psychosocial variables to identify subtypes of TMD patients in a primary health care setting based on pain-related disability.METHODS:Consecutive TMD pain patients (n = 399) seeking treatment in a primary care setting completed a multidimensional pain questionnaire. Subtyping was based on the Graded Chronic Pain Scale (GCPS), and the patients were divided into a no-disability group (0 disability points), lowdisability group (1-2 disability points), and high-disability group (3-6 disability points). Psychosocial variables included RDC/TMD Axis II variables, anxiety, tension and stress, worry, catastrophizing, coping ability, general health, and other pain problems. Subtype differences were analyzed with t test, Wilcoxon rank-sum test, ANOVA, or Kruskal-Wallis test. A further analysis with multivariable logistic model was applied. All P values from pairwise comparisons were Bonferroni adjusted.RESULTS:Most (61%) of the patients belonged to the no-disability group, 27% to the low-disability group, and 12% to the high-disability group. When subtypes were compared, patients in the no-disability group appeared psychosocially well-functioning, with fewer symptoms related to psychosocial distress, better ability to control pain, and fewer jaw functional limitations and other pain problems. Patients in the high-disability group reported the highest levels of symptoms of depression and somatization, sleep dysfunction, worry, and catastrophizing thoughts. The low-disability patients formed an intermediate group between the no-disability and high-disability groups.CONCLUSION:The results suggest that GCPS-related disability scoring can be used as a simple screening instrument in primary care settings to identify individuals with different, clinically relevant psychosocial subtypes.

AIMSTo evaluate the effectiveness of a prefabricated appliance and compare it to the effectiveness of a stabilization appliance in patients with temporomandibular joint (TMJ) pain.METHODSThis randomized, controlled multicenter study comprised 48 patients diagnosed with TMJ arthralgia according to the Research Diagnostic Criteria for Temporomandibular Disorders. The effectiveness of a prefabricated appliance (Relax), worn by half of the patients (referred to as the R group), was compared to the effectiveness of a stabilization appliance, worn by the other half of patients (S group). Treatment outcome was assessed according to the recommendations by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) on an intent-to-treat basis. To analyze the differences between groups, the chi-square test and the Mann-Whitney U test were used, while the Friedman analysis of variance (ANOVA) on ranks was used for the analyses between baseline data and follow-up measurements, all with a significance level set at P < .05.RESULTSThere were no differences between the groups at baseline. A 30% reduction of pain intensity was reported by 62.5% of the R group and 58.3% of the S group at the 10-week follow-up; 58% and 50.3%, respectively, at the 6-month follow-up; and 41.7% in both groups at 12 months. At the 12-month follow-up, pain intensity had decreased and physical function had improved in both groups (P < .005 and P < .016, respectively), without significant group differences. Emotional function (depression and nonspecific physical symptoms) did not change. Overall improvement of "better" to "symptom-free" was observed in 67% of the R group and 58% of the S group. No side effects occurred.CONCLUSIONThe effectiveness of the prefabricated appliance seems to be similar to that of the stabilization appliance in alleviating TMJ pain. Since the prefabricated appliance requires only one visit for construction, it is convenient for both the general practitioner and for the patient.

AIMS:To assess Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis II variables in an initial psychosocial screening and as a part of biopsychosocial subtyping of Finnish referral patients with TMD pain for adjunct multidisciplinary assessment.METHODS:Consecutive Finnish referral patients with TMD pain (n = 135) participated in this questionnaire-based survey. Psychosocial screening was based on Graded Chronic Pain Scale (GCPS) and culturally adjusted Symptom Checklist 90-revised (SCL-90R) depression scale scores and subtyping on GCPS pain-related interference in accordance with previous treatment tailoring studies. Biopsychosocial subtyping variables included symptoms of depression and somatization, general health, pain-related worry, sleep dysfunction, and coping ability. Subtype comparisons were analyzed with Bonferroni adjusted P values and multivariable logistic regression (SAS 9.3).RESULTS:Based on psychosocial screening, 44% of the patients were psychosocially uncompromised (TMD subtype 1), 33% moderately, and 23% severely compromised (TMD subtypes 2 and 3). Compared to TMD subtype 1, TMD subtype 2 patients reported intermediate scores, and the most vulnerable TMD subtype 3 had the poorest general health, most elevated depression, somatization, worry and sleep dysfunction, and poor coping ability (P < .05). According to multivariable logistic regression, depression and worry levels were significantly higher in TMD subtype 3 compared to TMD subtype 1, whilst patients in TMD subtypes 1 and 2 reported significantly better coping ability compared to TMD subtype 3 (P < .05).CONCLUSION:The Finnish RDC/TMD Axis II was found reliable in initial TMD pain patient screening and with further biopsychosocial assessment identified three main TMD subtypes, two with compromised psychosocial profiles for adjunct multidisciplinary assessment.

The long-term effectiveness of a prefabricated oral appliance (R) was compared with a stabilisation appliance (S) in patients with myofascial pain. Sixty-five patients diagnosed with myofascial pain at two centres for Stomatognathic Physiology in Sweden and Finland were included in a randomised controlled trial using Research Diagnostic Criteria for Temporomandibular Disorders, with history questionnaires and clinical examinations performed by blinded examiners at baseline and at 6- and 12-month follow-ups. Patients were randomly assigned either to the R or the S group. Treatment outcome was measured according to IMMPACT for four chronic pain outcome domains: pain intensity, overall improvement, physical functioning and emotional functioning. Physical functioning was classified for Graded Chronic Pain severities and assessed by the Jaw Functional Limitation scale. Emotional functioning composed of scores of non-specific physical symptoms and depression. There were no differences between groups at baseline. At both follow-ups, all outcome domains showed significant within-group improvement, without significant differences between groups. At 12 months, 72% of all patients reported a 30% reduction in worst pain and 63% of the patients a 50% reduction in worst pain. Overall improvement 'better' to 'symptom-free' was observed in 81% in the R and 64% in the S group at the 12-month follow-up. Graded Chronic Pain, Functional Limitation of the Jaw, non-specific physical symptoms and depression showed statistically significant reduction at 12-month follow-up. Results support the hypothesis that the effectiveness of the prefabricated appliance is similar to that of the stabilisation appliance in the long-term when treating patients with myofascial pain.

OBJECTIVE:To compare the short- and long-term effectiveness of a prefabricated occlusal appliance with that of a stabilization appliance when treating headache in patients with myofascial pain.MATERIAL AND METHODS:Sixty-six patients, 94% of whom suffered concomitantly from headache, at two centres for Stomatognathic Physiology in Sweden and Finland were included in a randomized controlled trial. History questionnaires and clinical examination according to the Research Diagnostic Criteria for Temporomandibular Disorders were used at baseline and at 10-week and 6- and 12-month follow-ups. Patients were randomly assigned to either a prefabricated (R) or a stabilization appliance (S) group.RESULTS:There were significant decreases in the frequency and intensity of headache in both groups at all follow-ups, without statistically significant differences between groups. At baseline, 23 patients in both groups reported recurrent-continuous headache and, at 12 months, seven in the R group and four in the S group. The mean intensity (numeric rating scale) of headache prior to treatment decreased significantly at 12 months from 5.3 to 2.1 in the R group and from 6.1 to 2.9 in the S group. At the 12-month follow-up, 56% of patients in the R group reported a 30% reduction in intensity of headache and 50% a 50% reduction. In the S group, corresponding values were 39% and 36%, respectively. Non-specific physical symptoms were significantly associated with frequency of headache at baseline and at 6 months, and with depression at 6 and 12 months.CONCLUSION:The effectiveness of the prefabricated appliance seems to be similar to that of the stabilization appliance in the treatment of headache in patients with myofascial pain in both the short and long term.

In many studies, the endocrinological response of individuals to different kinds of stresses has been tested. There seems to be widespread agreement that stress, depression, disability and dysfunctional illness behaviors are critical aspects of patients suffering from symptoms like pain, arising out of temporomandibular disorders (TMD). We aimed to explore treatment-induced changes in salivary cortisol, IgA and flow rate values in TMD patients suffering from myofascial pain. Temporomandibular disorders patients (n = 39) were randomized into two groups and treated with two different occlusal appliances. Perceived stress regarding family, work, economy, relationships, general health and stress in general was evaluated at baseline according to a verbal scale. Paraffin-stimulated saliva samples were collected before treatment and during follow-up at 6 and 10 weeks. Flow rate was measured immediately after the saliva collection while salivary cortisol and IgA were determined from samples stored at -70 degrees C. No clear association between reported stress and cortisol or IgA values could be observed at baseline. At 10 weeks follow-up, 92% of the patients felt 'better, much better, symptom-free' and no difference was found between the two appliance groups. Cortisol, IgA and flow rate values showed no systematic between appliance groups' differences. All salivary parameters showed interindividual differences but stayed intra-individually on a similar level throughout the study and no statistically significant changes could be observed when comparing before and after treatment levels. To conclude, there were no treatment-induced changes in saliva parameters despite successful appliance therapy in myofascial pain patients.

The aim of the present study was to study changes in signs and symptoms of temporomandibular disorders (TMD) and factors predicting TMD signs in adolescents with and without headache. A population-based sample ( n = 212) of 13-year-olds with and without headache was re-examined at the age of 16. The study included a questionnaire, face-to-face interview and somatic examination. In addition, a neurological examination, a muscle evaluation and a stomatognathic examination were performed. Significant changes were seen in TMD signs during the follow-up, but TMD signs at the end of the follow-up could not be predicted by baseline headache, sleeping difficulties, depression or muscle pain. TMD signs at the age of 16 were associated with female gender and muscle pain. We conclude that considerable changes in TMD signs occur in the follow-up of adolescents with and without headache. Headache-related TMD are not predictable in adolescents with and without headache.

AIMS:To compare the short-term effectiveness of a stabilization appliance with a prefabricated occlusal appliance in myofascial pain patients in a randomized controlled trial.METHODS:Sixty-five patients at 2 centers were assigned to a stabilization appliance group (S group, n = 33) or a prefabricated appliance (Relax) group (R group, n = 32). The patients had been suffering from temporomandibular disorder (TMD) pain for 3 months to 40 years. The patients were examined for symptoms and signs of temporomandibular disorders according to the Research Diagnostic Criteria for TMD and treated by a general practitioner. Treatment outcomes regarding pain, registered on a visual analog scale, and overall ratings of pain, registered on a verbal scale, were evaluated at 6- and 10-week follow-up appointments, and the data from the groups were compared statistically.RESULTS:The main treatment outcome in the 2 groups was a positive improvement of overall symptoms without any statistically significant differences between groups at either 6 or 10 weeks. At the 6-week follow-up, 72% of all patients reported a 30% reduction of the worst pain, and 55% of the patients reported a 50% reduction of the worst pain, whereas at the 10-week follow-up, the percentages were 69% and 61%, respectively. According to the verbal scale, 85% of all patients reported themselves to be "better," "much better," or "symptom-free" at the 6-week follow-up, and 83% reported this at the 10-week follow-up.CONCLUSION:The effectiveness of the prefabricated occlusal appliance seemed to be the same as that of the stabilization appliance. The prefabricated appliance can therefore be recommended as a short-term therapy in adult patients with myofascial pain.

The effectiveness of a prefabricated occlusal appliance in a long-term perspective (Finland)