Diagnostic Criteria - Problems

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Utredning av ansiktssmärta

Thomas List

Arne Petersson

•

Reliability

•

Validity

•

Operationalization

•

Clinical relevance-treatment and prognosis

•

Most classification systems: one axis – one focus

– muscle or joint pain

2014-03-04 Malmö University | Thomas List och Arne Petersson

Biobehavioral pain model

2014-03-04 Malmö University | Thomas List och Arne Petersson

RDC/TMD

Comprises:

A dual axis approach.

• Clinical TMD Conditions (Axis I) • Psychological disorders and psychosocial

dysfunction (Axis II)

Specifications for TMD Examination.

Strict diagnostic criteria.

2014-03-04 Malmö University | Thomas List och Arne Petersson

Research Diagnostic Criteria for

TMD (RDC/TMD)

2014-03-04 Malmö University | Thomas List och Arne Petersson

Major steps from the RDC/TMD to the

DC/TMD

Year Event

1992 Publication of RDC/TMD 2001-2008 Validation Project

2008 Symposium at IADR Conference (Toronto) 2009 International RDC/TMD Consensus Workshop at IADR

Conference (Miami)

2010 Publication of Major findings by Validation Project 2010 Symposium at IADR Conference (Barcelona) 2011 International RDC/TMD Consensus Workshop at IADR

Conference (San Diego). Expanded Taxonomy of DC/TMD 2012 Symposium of DC/TMD Conference at at IADR Conference

(Iguacu Falls). Expanded Taxonomy of DC/TMD 2013 Finalization of Expanded Taxonomy of DC/TMD at IADR

Conference (Seattle)

2014 Publication of DC/TMD and Expanded taxonomy of TMD

2014 Symposium of Expanded taxonomy of TMD at IADR Conference (Cape Town).

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IADR Miami 2009

International Consensus Workshop:

Convergence on an Orofacial Pain Taxonomy

•

Workshop participation

:

•

International RDC/TMD Consortium Network

•

SIG Orofacial Pain

•

NIDCR

•

American Academy of Orofacial Pain

•

European Academy of Craniomandibular

Disorders

•

International Headache Society

•

Other disciplines included: radiology, psychology,

ontology, neurology and patient advocacy.

2014-03-04 Malmö University | Thomas List och Arne Petersson

Description of the Workshop

•

Presentations: Systematic review

guidelines, biomedical ontology

and patient advocacy.

•

Workgroup made revisions of

respective parts of the

RDC/TMD

•

Each workgroup presented the

recommendations for critique by

the others.

•

Delphi-like voting for determing

whether sufficient concensus

had been achieved.

2014-03-04

Malmö University | Thomas List och Arne Petersson Malmö University | Thomas List och Arne Petersson 2014-03-04

Diagnostik

Malmö högskola | Orofaciala smärtenheten | Per Alstergren 2014-03-04

Alla tillstånd

Expanded taxonomy

IADR San Diego 2011

Expanding the Scope of the Diagnostic Criteria for

Temporomandibular Disorders (DC/TMD)

Represented Organizations • International RDC/TMD

Consortium Network • IASP Orofacial Pain SIG • American Academy of Orofacial

Pain • European Academy of

Craniomandibular Disorders • International Headache Society • National Institute of Dental and

Craniofacial Research

Expanded Taxonomy for Temporomandibular Disorders

Peck et al. J Oral Rehab 2014; 41: 2-23.

MALMÖ HÖGSKOLA

I. TEMPOROMANDIBULAR JOINT DISORDERS 1 Joint pain

A Arthralgia

B Arthritis 2 Joint disorders

A Disc disorders

1 Disc displacement with reduction

2 Disc displacement with reduction with intermittent locking 3 Disc displacement without reduction with limited opening

4 Disc displacement without reduction without limited opening B Hypomobility disorders other than disc disorders 1 Adhesions/Adherence 2 Ankylosis a Fibrous b Osseous C Hypermobility disorders 1 Dislocations a Subluxation b Luxation

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Expanded Taxonomy for Temporomandibular Disorders

MALMÖ HÖGSKOLA

3 Joint diseases

A Degenerative joint disease

1 Osteoarthrosis 2 Osteoarthritis B Systemic arthritides

C Condylysis/Idiopathic condyle resorption D Osteochondritis dissecans E Osteonecrosis F Neoplasm G Synovial chondromatosis 4 Fractures 5 Congenital/developmental disorders A Aplasia B Hypoplasia C Hyperplasia II. MASTICATORY MUSCLE DISORDERS III. HEADACHE

IV. ASSOCIATED STRUCTURES 1 Coronoid hyperplasia

DC/TMD Questionnaire

Symptom questionnaire

Pain intensity

Limitation in daily activities

Jaw function

Psychosocial health

Pain drawing

Demographics

Pain and headache location

”Pain during the last 30 days”

2014-03-04 Malmö University | Thomas List och Arne Petersson

Maximum unassisted opening:

Pain Familiar Pain Familiar Headache Temporalis N Y N Y N Y Masseter N Y N Y TMJ N Y N Y Other M Musc N Y N Y Non-mast N Y N Y

”I would like you to open your

mouth as wide as you can, even

if it is painful”

2014-03-04 Malmö University | Thomas List och Arne Petersson

Decision trees

Malmö University | Thomas List och Arne Petersson 2014-03-04

Kalibrering

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Myalgia

Sensitivity 0.84; Specificity 0.95

History:

1. Pain in the jaw, temple, in the ear, or in front of ear; AND

2. Pain modified with jawe movement, function or parafunction. AND

Exam:

1. Confirmation of pain location in the area of the temporalis or masseteer muscle(s); AND 2. Report of familiar pain in the temporalis or masseter

with at least 1 of the following provocation tests: a. Palpation of the temporalis or masseter muscles(s); OR

b. Maximum unassisted or assisted opening.

Malmö University | Thomas List och Arne Petersson 2014-03-04

Expanded Taxonomy for Temporomandibular Disorders

MALMÖ HÖGSKOLA

I. TEMPOROMANDIBULAR JOINT DISORDERS 1 Joint pain

A Arthralgia

B Arthritis 2 Joint disorders

A Disc disorders

2 Disc displacement with reduction with intermittent locking 3 Disc displacement without reduction with limited opening 4 Disc displacement without reduction without limited opening B Hypomobility disorders other than disc disorders 1 Adhesions/Adherence 2 Ankylosis a Fibrous b Osseous C Hypermobility disorders 1 Dislocations a Subluxation b Luxation

Arthralgia

Sensitivity 0.91; Specificity 0.96

History:

1. Pain in the jaw, temple, in the ear, or in front of ear; AND

2. Pain modified with jaw movement, function or parafunction.

AND

Exam:

1. Confirmation of pain location in the area of the TMJ(s); AND

2. Report of familiar pain in the TMJ with at least 1 one of the following provocation tests:

a. Palpation ofthe lateral pole; OR

b. Maximum unassisted or assisted opening, right or left lateral movements, or protrusive movements.

Malmö University | Thomas List och Arne Petersson 2014-03-04

Palpation TMJ joint

TMJ Pain Familiar Pain Referred Pain Lateral pole (0,5 kg) N Y N Y N Y Around lateral pole (1kg) N Y N Y N Y 2014-03-04 Malmö University | Thomas List och Arne Petersson

Expanded Taxonomy for Temporomandibular Disorders

MALMÖ HÖGSKOLA

I. TEMPOROMANDIBULAR JOINT DISORDERS 1 Joint pain

A Arthralgia B Arthritis 2 Joint disorders

A Disc disorders

2 Disc displacement with reduction with intermittent locking 3 Disc displacement without reduction with limited opening

4 Disc displacement without reduction without limited opening B Hypomobility disorders other than disc disorders 1 Adhesions/Adherence 2 Ankylosis a Fibrous b Osseous C Hypermobility disorders 1 Dislocations a Subluxation b Luxation

Disc Displacement with Reduction

(

Sensitivity 0.80; specificity 0.97 without imaging)

History is positive for at least one of the following: 1. In the last 30 days, any TMJ noises(s)present with

jaw movements or function; OR

2. Patient report of any noise present during exam; AND Examination is positive at least for one of the following:

1. Clicking popping, and/or snapping noise detected during both opening and closing movements, detected by palpation during at least one of three repetitions of jaw opening and closing movements; OR 2a. Clicking popping, and/ or snapping noise detected with palpation during

at least one of three repetitions of opening and closing movements(s);AND

2b. Clicking popping, and/ or snapping noise detected with palpation during at least one of three repetitions of right and left lateral or protrusive movement(s).

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Disc Displacement without Reduction

with Limited Opening (DC/TMD)

(

I. History is positive for both of the

following:

1. Jaw lock or catch so that it would not

open all the way; AND

2. Limitation in jaw opening severe enough

to interfere with ability to eat.

AND

II. Examination is positive for the following:

1.Maximum assisted opening (passive

stretch)

< 40mm. Including vertical incisal overlap

.

DISC DISORDERS

MALMÖ HÖGSKOLA

Imaging:

Diagnostic imaging should only be

considered after a history and physical

examination, indicates that information from

imaging will influence patient care. Further

research is needed.

MRI

is the prefered modality

Peck et al. 2014

Normal disc position closed mouth sagittal and coronal

views

(Ahmad et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:844-860)

i. In the sagittal plane, relative to the superior aspect of the condyle, the border between the low signal of the disc and the high signal of the retrodiscal tissue is located between the 11:30 and 12:30 clock positions; and

ii. In the sagittal plane, the intermediate zone is located between the anterior-superior aspect of the condyle and the posterior-inferior aspect of the articular eminence; and

iii. In the oblique coronal plane, the disc is centered between the condyle and eminence in the medial, central, and lateral parts.

Proton density, Sagittal,

Closed mouth

Normal disc position

T2

Proton density

Coronal

Closed mouth

i. In the sagittal plane, relative to the superior aspect of the condyle, the low signal of the disc and the high signal of the retrodiscal tissue are located anterior to the 12:30 clock position; and ii. In the sagittal plane, the intermediate zone of the disc is located anterior to the condyle; or iii. In the axially corrected coronal plane, the disc is not centered between the condyle and eminence in either the medial or the lateral parts.

Disc displacement

(Ahmad et al. 2009)

Westesson 1982

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Closed mouth

Disc displacement

Proton density, Coronal

Closed mouth

Lateral disc displacement

T2

Disc position: open-mouth sagittal views

Normal disc position: The intermediate zone is

located between the condyle and the articular

eminence.

Persistent disc displacement: The intermediate

zone is located anterior to the condylar head.

(Ahmad et al. 2009)

Proton density

Sagittal

Open mouth

Normal disc

position

Closed mouth

Disc displacement

Open mouth

Without reduction

Disc diagnosis for TMJ

_{(Ahmad et al. 2009)}

A. Normal: Disc location is normal on closed- and

open-mouth images.

B. Disc displacement with reduction: Disc location is

displaced on closed-mouth images but normal in

open-mouth images.

C. Disc displacement without reduction: Disc

location is displaced on closed-mouth and

open-mouth images.

D. Indeterminate: Disc location is not clearly normal

or displaced in the closed-mouth position.

E. Disc not visible

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MRI

1.5 - 3 Tesla

Axially corrected sagittal and coronal images

Closed and open mouth positions

Proton-density PD or T1, and T2

MRT

1. Diskens läge 2. Diskens form

Normal: Bikonkav i sagitalplanet Deformerad: Alla andra former än bikonkav Disk går ej att identifiera

3. Effusion-ledvätska

Ingen: Ingen förhöjd signal i ledrummen vid T2-viktade bilder Lätt (slight) effusion: En förhöjd signal i något av ledrummen som håller sig längs konturerna av disken, fossa, tuberkeln eller condylen Kraftig (frank) effusion: En förhöjd signal i något av ledrummen som sträcker sig utanför de osseösa konturerna av fossa, tuberkeln, condylen och som har en konvex konfiguration I den anteriora eller posteriora recessen

4. Förkalkningar i leden

5. Osseösa förändringar (erosion, osteofyt, subchondral cysta, avplaning) 6. Benmärgsförändringar (ödem, scleros)

MALMÖ HÖGSKOLA

Proton density

T2

The Efficacy of Diagnostic Imaging

Fryback & Thornbury (1991)

1 2 3 4 5 6 Technical Diagnostic accuracy Diagnostic thinking Societal Patient outcome Therapeutic

Efficacy levels

TMJ d

isc position

MALMÖ HÖGSKOLA (Limchaichana et al. 2006)

Sensitivity and specificity

7 publications moderate and 7 low levels of evidence.

Diagnostic criteria and disease prevalences varied

substantially.

Sagittal images: sensitivity 0.86, specificity 0.63

Coronal images: sensitivity 0.50-0.87, specificity

0.80-0.92

Combining sagittal and coronal images: sensitivity

0.60-0.90, specificity 0.92-1.0

TMJ d

isc position

Observer performance

(Limchaichana et al. 2006)

4 publications with moderate level of evidence

Intraobserver agreement

Kappa mean, 0.85 good

Interobserver agreement

very good for high quality images and

disk displacement without reduction (Kappa 0.91), and poor

for slight anterior disk displacement (Kappa 0.19).

Interobserver agreement - Kappa; (

Ahmad et al. 2009)

Any disc displacement 0.84

Disc displacement with reduction 0.78

Disc displacement without reduction 0.94

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Web-based calibration of observers using MRI

of the temporomandibular joint

Hellén-Halme, Hollender, Janda, Petersson. Dentomaxillofac Radiol 2012; 41, 656–661.

http://www.mah.se/od/rad/tmj

The efficacy of magnetic resonance imaging in the

diagnosis of degenerative and inflammatory

temporomandibular joint disorders: a systematic

literature review.

Limchaichana et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:521-36.

•

No publication had a high level of evidence

•

No publication reported diagnostic thinking

efficacy or therapeutic efficacy

•

The evidence grade for diagnostic accuracy

expressed as sensitivity, specificity, and predictive

values was limited to insufficient

Expanded Taxonomy for Temporomandibular Disorders

MALMÖ HÖGSKOLA

3 Joint diseases

A Degenerative joint disease

1 Osteoarthrosis 2 Osteoarthritis

B Systemic arthritides

Degenerative joint disease

(

I. History is positive for at least one of the following: 1. In the last 30 days, any TMJ noises(s)present with

jaw movements or function; OR

2. Patient report of any noise present during exam. AND

II. Examination is positive at least for one of the following: 1. Crepitus detected with palpation during at least one

of the following; opening, closing, right or left lateral or protrusive movements (s).

Expanded Taxonomy for Temporomandibular Disorders

MALMÖ HÖGSKOLA

Degenerative joint disease (DJD)

•

Deterioration of articular tissue with osseous changes. DJD can

be sub-classified as:

Osteoarthrosis - DJD without arthralgia

Osteoarthritis – DJD with arthralgia

•

Flattening and and /or subcortical sclerosis are considered

indeterminant findings for DJD and may represent normal

variation, aging, remodelling or a precursor to frank DJD.

Imaging:

When this diagnosis needs to be confirmed.

TMJ CT/CBCT criteria are positive for at least one of the following:

1. Subchondral cyst 2. Erosion(s) 3. Generalized sclerosis 4.

Osteophyte(s)

Osseous diagnoses.

Ahmad et al. 2009

A. No osteoarthritis

i. Normal relative size of the condylar head; and ii. No subcortical sclerosis or articular surface flattening; and iii. No deformation due to subcortical cyst, surface erosion, osteophyte, or generalized sclerosis.

B. Indeterminate for osteoarthritis i. Normal relative size of the condylar head; and

ii. Subcortical sclerosis with/without articular surface flattening; or

iii. Articular surface flattening with/without subcortical sclerosis; and

iv. No deformation due to subcortical cyst, surface erosion, osteophyte, or generalized sclerosis.

C. Osteoarthritis

i. Deformation due to subcortical cyst, surface erosion, osteophyte, or generalized sclerosis.

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Osseous changes. Diagnostic accuracy.

CBCT of condyle.

Hintze et al. 2007 Sensitivity Lateral Frontal Specificity Lateral Frontal Flattening 0,23 0,40 0,87 0,90 Defect 0,15 0,20 0,95 0,96 Osteophyte 0,15 0,96 Honda et al. 2006 0,80 1,0

Osseous changes. Observer agreement.

Ahmad et al. 2009 MALMÖ HÖGSKOLA

Kappa

Panoramic radiography 0.27

MRI 0.58

CT 0.71

Hur påverkas diagnos och behandlingsval av

röntgenfynden vid TMD?

MALMÖ HÖGSKOLA

•

To test changes in diagnosis

and management after

radiographic examination

•

To evaluate the associations

between specific findings in

TMJ tomograms and changes in

management strategy.

Diagnostic thinking

The diagnosis (RDC/TMD) was changed in 27% of

the patients after tomography, often arthralgia >

osteoarthritis

Wiese 2008

Therapeutic thinking

Choice of treatment with and without tomography.

3 clinics.

The choice of treatment was changed in 27% of the

patients – mostly slight changes in medication and

fysiotherapy.

Differences existed between the clinics

Wiese 2008

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Expanded Taxonomy for Temporomandibular Disorders

MALMÖ HÖGSKOLA

3 Joint diseases

A Degenerative joint disease 1 Osteoarthrosis 2 Osteoarthritis

B Systemic arthritides

Systemic Arthritides

History positive for both of the following

:

1. Rheumatic diagnosis of a systematic inflammatory joint disease, AND

2a. Pain in the jaw, temple, in the ear, or in front of ear; AND

2b. Pain modified with jaw movement, function or parafunction; AND

Examination positive for both of the

following

1. Rheumatic diagnosis of a systematic joint disease; AND 2a. Arthritis signs and symptoms as deined in I.1.B; OR 2b. Crepitus detected with palpation during maximum unassisted opening, maximum assisted opening, right or left lateral movements, or protrusive movements.

Malmö University | Thomas List och Arne Petersson 2014-03-04

Systemic arthritides

Note that imaging in early stages of the disease may not

demonstrate any osseous findings.

Imaging

If osseous changes are present, TMJ CT/CBCT or MR imaging is

positive for at least one of the following:

1. Subchondral cyst(s)

2. Erosion(s)

3. Generalized sclerosis

4. Osteophyte(s)

Åkerman et al. (1991). Nittio patienter med RA. 2/3 uppvisade

röntgenförändringar i käklederna, oftast erosioner jämförbara

med förändringarna i händer och fötter.

Expanded Taxonomy for Temporomandibular Disorders

MALMÖ HÖGSKOLA

3 Joint diseases

A Degenerative joint disease 1 Osteoarthrosis 2 Osteoarthritis B Systemic arthritides

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Synovial chondromatosis

SBU

:

Synovial chondromatos är en benign sjukdom

som innebär att ledhinnan i käkleden bildar fria

broskkroppar. Tillståndet behandlas t ex med

käkledkirurgi.

Socialstyrelsen: Tillståndet innebär en mycket stor

påverkan på den orala hälsan till följd av en stor

grad av vävnadsskada

Synovial Chondromatosis

History positive for at least one of the

following:

1. Report of preauricular swelling; OR 2. Arthralgia as defined in I.1.A; OR 3.Progressive limitation in mouth opening; OR 4. In the past month, any joint noise(s) present

II. Examination positive for at least one of

the following:

1. Preauricular swelling; OR 2. Arthralgia as defined in I.1.A; OR

3. Maximum assisted opening< 40 mm including vertical overlap; OR

4. Crepitus as per I3.A (DJD)

Malmö University | Thomas List och Arne Petersson 2014-03-04

Synovial chondromatosis

Imaging:

TMJ MRI or CT/CBCT is positive for at least

one of the following:

1. MRI: multiple chondroid nodules, joint effusion

and amorphous iso-intensity signal tissues

within the joint space and capsule

2. CT/CBCT: loose calcified bodies in the soft tissues

of the TMJ

Synovial chondromatos

Case

Arne has pain in the first molar in his upper left

jaw. Tooth 27 was extracted by another dentist

because of a crack. Since the pain did not go

away, tooth 26 was then endodontically

treated several times,

but the pain is unchanged.

What do you do?

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2014-03-04 Malmö University | Thomas List och Arne Petersson

Definition Atypical Odontalgia

• Pain located in a region where a tooth has

been endodontically or surgically treated

• Chronic pain (> 6 months)

• No pathological cause detectable in clinical

or radiological examination

.

•

Synonyms: phantom tooth pain, idiopathic

toothache, CCDAP

2014-03-04 Malmö University | Thomas List och Arne Petersson

touch

Pressure pain Pin-prick

temperature

Pigg et al 2010 2014-03-04 Malmö University | Thomas List och Arne Petersson

Atypisk Odontalgi

A comparative analysis of MRI and radiographic examinations of patients with atypical odontalgia. Pigg, List, Abul-Kasim, Maly, Petersson. J Orofacial Pain 2014.

20 patienter diagnosticerade med atypisk odontalgi. Patienterna är undersökta med intraorala röntgenbilder, panoramaröntgen, CBCT och MRT med T1, T2 STIR, (3D CISS), T1 gd, T1 fs gd

Radiographic bone defect n (%) + – Total MRI changes in signal n (%) + 6 (30) 2 (10) 8 (40) – 3 (15) 9 (45) 12 (60) Total 9 (45) 11 (55) 20 (100) CBCT MRT T2 stir MRT T1 31 32 CBCT MRT T2 stir MRT T1 fs gd

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CBCT

MRT T2 stir

MRT T1 fs gd

Atypisk Odontalgi

• MRT visade inga signalförändringar i smärtregionen hos

majoriteten av patienterna (60%)

• Fynden vid MRT och CBCT var signifikant korrelerade och

gav samma resultat hos 75% av patienterna

När röntgenfynden är osäkra, speciellt i regioner där ett

flertal behandlingar har genomförts, kan MRT styrka

argumentet att undvika vidare tandbehandling. Fler studier

behövs för att utreda nyttan av MRT.

DC/TMD i Grundutbildningen och

Specialistutbildningen

Malmö University | Thomas List och Arne Petersson 2014-03-04

RDC/Orofacial Pain

Axis I : Diagnosis Axis II: Psychosocial assessment Axis III: Biomarkers