Journal of Oral & Facial Pain and Headache, 04/2002

Aims: To test the usefulness of tailoring cognitive-behavioral therapy (CBT) for patients with temporomandibular disorders (TMD) who demonstrated poor psychosocial adaptation to their TMD condition, independent of physical diagnosis. Methods: A randomized clinical trial compared a 6-session CBT intervention delivered in conjunction with the usual TMD treatment to the usual conservative treatment by TMD specialist dentists. For study inclusion, Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), Axis II criteria, were used to target patients with elevated levels of TMD pain-related interference with daily activities, independent of physical diagnosis (ie, Axis I). Results: At the post-treatment assessment, about 4 months after the baseline evaluations, the comprehensive care group, when compared to the usual treatment group, showed significantly lower levels of characteristic pain intensity, significantly higher self-reported ability to control their TMD pain, and a strong trend (P = .07) toward lower pain-related interference in daily activities. From post-intervention to 1-year follow-up, all subjects showed improvement. At the 1-year follow-up, the comprehensive care group, while not losing any of its early gains, was not significantly different from the usual care group with regard to reported levels of pain, ability to control pain, and levels of interference in activities. For many of these psychosocially disabled TMD patients, pain and interference 1 year after treatment remained at the same or higher levels than those observed at baseline among a group of patients selected for a separate randomized clinical trial on the basis of better psychosocial adaptation. Conclusion: The 6-session CBT intervention for patients with heightened psychologic and psychosocial disability was effective in improving pain-related variables over the course of the CBT in conjunction with usual treatment, but was too brief an intervention to result in further improvement after the sessions ended. Patient ratings of treatment satisfaction and helpfulness were high for both groups, but they were significantly higher for the comprehensive care group. Keywords: temporomandibular disorders, cognitive-behavioral therapy, RDC/TMD

Aims: To identify differences between 2 groups of patients with temporomandibular disorders (TMD), those with masticatory muscle pain (MMP) versus intracapsular pain (ICP), and to compare these differences on behavioral and psychosocial domains. Methods: There were 435 patients in the MMP group and 139 patients in the ICP group. The overall sample was 88.2% female and had an average age of 36.1 years (SD = 11.7). Patients completed measures of psychological symptoms (SCL-90), pain severity (MPI), sleep (PSQI), activity (MBI), and life stressors (PCL). Heart rate and blood pressure were also measured, and a complete medical/dental history was taken for each patient. Results: Results indicated no significant difference in pain severity or duration between the 2 groups (P > .05). The ICP group, however, reported fewer affective symptoms of pain than the MMP group (t = 6.8, P = .01). The ICP group had twice as many adaptive copers as dysfunctional patients (x2 = 7.84, P .01), while there was no significant difference between these 2 categories for the MMP group (P > .05). Finally, the ICP group reported fewer psychological symptoms (P .05), better sleep quality (F = 7.54, P = .01), and fewer life stressors (F = 7.00, P = .01) than the MMP group. Conclusion: In contrast to many previous studies, the data set in this study showed no differences in pain severity and duration between the MMP and the ICP groups. Even though pain severity levels were equivalent, the MMP diagnostic group of chronic TMD patients demonstrated more dysfunctional behavioral profiles and significantly higher psychological distress than the ICP subgroup. Keywords: pain, myofascial pain, masticatory muscle pain, intracapsular pain, psychosocial issues

Aims: To examine various dimensions of reliability of the Craniomandibular Index, a commonly used instrument for quantifying the severity of signs and symptoms of temporomandibular disorders. Methods: Classical psychometric theory and generalizability theory were used to assess the reliability of data obtained from a calibration study of examiners participating in a multi-site clinical trial and from a random community sample. Results: The reliability of aggregate scores formed by summing individual binary scored items was high, with intraclass correlations ranging from 0.81 to 0.88. When it was required that examiners recognize and agree upon a specific pattern of signs and symptoms exhibited by a patient, however, reliability dropped dramatically (multivariate kappas ranged from 0.26 to 0.32). A group of practicing examiners also showed limited ability to agree with the pattern of signs and symptoms identified by a "gold standard" examiner (multivariate kappas ranging from 0.25 to 0.32). Generalizability analysis failed to identify the specific sources of measurement error that played a major role in limiting reliability but demonstrated that generalizability of aggregate scores was very high. Conclusion: Methods of classical psychometric theory and generalizability theory support the conclusion that the reliability of aggregate scores is acceptably high. Individual items assessing certain aspects of jaw mobility and joint sounds are measured with poor reliability. Reliability declines when it is defined as the ability of examiners to agree among themselves upon a specific constellation of signs and symptoms or their ability to identify correctly a "correct" constellation identified by an expert examiner. Keywords: Craniomandibular Index, temporomandibular disorders, reproducibility of results, psychometrics, generalizability theory

Aims: The operational definitions for the Craniomandibular Index (CMI) were redesigned to conform precisely to those of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), resulting in a single examination protocol, the Temporomandibular Index (TMI). The objectives were to evaluate interexaminer reliability of the TMI as well as its criteria and construct validity for measurement of TMD severity. Methods: Interexaminer reliability of the TMI was assessed on 12 subjects. Criterion validity of the TMI was evaluated relative to the CMI, the latter having established validity. Construct validity of the TMI was evaluated for its capacity to differentiate TMD patients (n = 79) from normal subjects (n = 20) and to detect changes in severity over time. Results: The examiners' average TMI scores were 0.27 ± 0.19 (SD) and 0.26 ± 0.20. Agreement was excellent, with an intraclass correlation coefficient (ICC) of 0.93. The scores for the TMI and the CMI correlated highly, with an ICC of 0.97. Statistical contrasts between the symptomatic groups and the normal subjects were highly significant (P .001). In 20 TMD patients who underwent treatment for their disorder, their mean change of 0.12 from their pretreatment TMI scores was highly significant (P .001). Conclusion: This study has provided statistical evidence for the clinical reliability and validity of the TMI, which indicates that the RDC examination protocol is appropriate for determining TMD severity by the TMI algorithm, and diagnosis of TMD subtypes by the RDC algorithm. Keywords: temporomandibular disorder, reliability, validity, outcomes, Research Diagnostic Criteria, Craniomandibular Index

Aims: Burning mouth syndrome (BMS) primarily affects postmenopausal women and is often difficult to treat successfully. Treatment outcomes have been problematic because of failure to distinguish between patients with BMS and patients presenting with oral burning (OB) resulting from other clinical abnormalities. The purpose of this study was to determine characteristics that might uniquely identify BMS patients from patients with OB and to determine whether proper classification influences treatment outcome. Methods: The clinical sample consisted of 69 patients (83% female) with an average age of 62 years, pain duration of 2.45 years, and visual analog scale pain rating of 49 mm (rated from 0 to 100 mm). All patients underwent a clinical exam and completed the Multidimensional Pain Inventory and Symptom Checklist 90-Revised. Results: There were no differences between the BMS and OB groups with respect to age, pain duration, pain intensity, life interference, and levels of psychologic distress. Patients with OB demonstrated more clinical abnormalities than BMS patients. Hyposalivation and greater use of prescription medications, most notably hormone replacement therapy, were more common in the OB group compared with the BMS group. When treatment was provided that corrected an identifiable abnormality, significantly more OB than BMS patients reported greater than 50% relief from baseline pain rating. Conclusion: These data indicate that while BMS and OB groups may initially present with similar clinical and psychosocial features, they are distinguishable with careful diagnosis that often enables successful management of symptoms for each group. Keywords: burning mouth syndrome, classification, treatment outcome, psychological distress

Aims: To study the neurogenic effects of a cyclooxygenase-2 (COX-2) inhibitor, rofecoxib, in an animal model of persistent inflammation. Methods: Arthritis was induced within the temporomandibular joint (TMJ) by placing complete Freund's adjuvant (CFA) within the superior joint space of the TMJ in adult male rats. The CFA animals were divided into 2 groups, with 1 group given the COX-2 inhibitor, rofecoxib, on days 21 through 28. Tissues were taken from experimental and control animals 4 weeks post-injection and analyzed by radioimmunoassay. The inflammatory-related neuropeptide, immunoreactive calcitonin gene-related peptide (CGRPi), was assayed from both the TMJ tissues and the trigeminal brain stem subnucleus caudalis. Results: CGRPi content was significantly increased in TMJ tissues within the untreated CFA group (72%) and was found to be effectively no different between the CFA/COX-2 group and controls. Trigeminal brain stem subnucleus caudalis CGRPi levels were not different between the groups. Conclusion: These results suggest that use of an inhibitor selective for the inducible form of cyclooxygenase enzyme, COX-2, may significantly attenuate the neurogenic component in an inflammatory TMJ animal model. Keywords: calcitonin gene-related peptide, temporomandibular joint, experimental arthritis, inflammation, complete Freund's adjuvant