First evidence-based diagnostic criteria published for temporomandibular disorders

The first evidence-based diagnostic criteria have been developed to help health professionals better diagnose temporomandibular disorders (TMD), commonly known as TMJ, a group of often-painful jaw conditions that affect an estimated 10 to 15 percent of Americans. The diagnostic criteria, developed by researchers in North America, Europe and Australia, are professional recommendations on how best to detect a disease or condition.

The new criteria, supported in part by the National Institutes of Health, comprise an improved screening tool to help researchers and health professionals including dentists more readily differentiate the most common forms of TMD and reach accurate diagnoses that are grounded in supportive scientific evidence. Historically, diagnostic criteria for TMD have been based on a consensus of expert opinion and often reflect a shared clinical perspective. None have been rigorously tested by scientists.

“We’ve had diagnostic criteria for years,” said Eric Schiffman, D.D.S., a co-lead author on the article, who studies TMD at the University of Minnesota School of Dentistry, Minneapolis. “What is unique here is instead of a panel of experts empirically deciding best practices, we relied on science as a methodology to test our best assumptions and see if we were actually correct.”

Called DC/TMD, the latest criteria are published today in the winter issue of the Journal of Oral and Facial Pain and Headache. They are available online at the International RDC/TMD Consortium Network website: http://www.rdc-tmdinternational.org/TMDAssessmentDiagnosis/DCTMD.aspx External Web Site Policy

Although TMD is commonly considered a jaw problem, researchers have determined that most people with chronic temporomandibular problems also contend with other ailments. In 1992, the Research Diagnostic Criteria for TMD (RDC/TMD) reflected this awareness. They were the first to integrate biological, psychological, and social factors into two distinct protocols, or axes. Axis I was designed to evaluate the physical diagnoses, while Axis II characterized the nature of a person's pain, distress, and disability. The criteria were translated into 18 languages and become the most widely used diagnostic system among TMD researchers.

But the RDC/TMD dual axes represented a first step with biopsychosocial diagnostic criteria. In the early 2000s, the NIH's National Institute of Dental and Craniofacial Research (NIDCR) assembled a group of experts to lead the first comprehensive assessment of the criteria. The group found Axis I in particular to be less valid than previously thought, leading to a mandate from the TMD clinical and research communities to create the diagnostic equivalent of RDC/TMD 2.0.

All agreed at the outset that the "R" was no longer needed. Research criteria, while useful for scientists in the laboratory and clinic, can leave researchers and health care providers using different diagnostic terms, measures, and tools.

“A common language allows clinicians to communicate more easily to researchers about their daily diagnostic challenges,” said Richard Ohrbach, D.D.S., Ph.D., a co-lead author on the publication who studies TMD at the University at Buffalo School of Dental Medicine in New York. “Conversely, a common language allows research findings to be more easily integrated into a clinical setting and improve patient care.”

The DC/TMD start with a refined version of Axis I, the physical assessment. It begins with an easily administered patient questionnaire that is specially designed to detect pain-related TMD. If TMD is detected, the protocol moves on to newly crafted diagnostic criteria to help practitioners differentiate among the common subtypes. In field tests, the diagnostic criteria for painful TMD were found to have at least 86 percent sensitivity and 97 percent specificity. Sensitivity refers to how well a test identifies a person with a given ailment, while specificity characterizes the ability to identify correctly those who are not affected.

Axis II, the psychosocial assessment, screens patients to assess pain location, pain intensity, pain-related disability, psychological distress, degree of jaw dysfunction, and presence of oral habits (i.e.,e.g. grinding teeth) that may contribute to the dysfunction. If more information is needed, a more comprehensive follow-up questionnaire is available to tap into additional anxiety measures and the possible presence of other pain-causing physical ailments. Both instruments have been scientifically validated.

“By diagnosing the person, beyond only the physical condition, a whole avenue of treatment options opens up,” said Schiffman. “Instead of prescribing mouth guards, exercises, or surgery, practitioners can consider trying bio-behavioral treatments including relaxation techniques and biofeedback to help the patient successfully manage their TMD. In short, you can better customize the treatment to fit the whole person, not just their disorder.”

The National Institute of Dental and Craniofacial Research (NIDCR) is the Nation’s leading funder of research on oral, dental, and craniofacial health. The NIDCR-supported International RDC/TMD Consortium Network provided the investigative framework for researchers from North America, Europe, and Australia to develop an improved diagnostic system and test its validity. Visit the NIDCR website at http://www.nidcr.nih.gov.

Antibacterial Agent Boosts Toothpaste Effectiveness

Source: Health Behavior News Service

Regular use of fluoride toothpaste containing triclosan, an antibacterial agent, and a copolymer, which helps prevent the triclosan from being washed away by saliva, reduces plaque, gingivitis, and bleeding gums and slightly reduces tooth decay compared to fluoride toothpaste without those ingredients, finds a new review in The Cochrane Library.

"We are very confident that adding triclosan and copolymer to a fluoride toothpaste will lead to additional benefits, in terms of less plaque, inflammation, bleeding, and tooth decay," said Philip Riley, a researcher at the University of Manchester in England, and a co-author of the study. But he added, "We don’t know how important the effects are clinically."

Tooth decay and gingivitis are the main causes of tooth loss. Both are caused by plaque, the film of bacteria that builds up on teeth, and if left untreated, can lead to periodontitis, a more serious gum disease that can cause pain and loose teeth. A team from the Cochrane Oral Health Group reviewed 30 published studies of toothpastes containing triclosan and copolymer.

Their analysis of the combined data found a 22 percent reduction in plaque, a 22 percent reduction in gingivitis, a 48 percent reduction in bleeding gums, and a 5 percent reduction in tooth decay (cavities) compared to toothpaste with fluoride alone. However, they did not find significant evidence that triclosan/copolymer toothpaste reduced the incidence of periodontis more than toothpaste without the combination. No adverse reactions to triclosan or the copolymer were reported.

The findings of the review are not surprising, according to Clifford Whall, Ph.D., director of the American Dental Association's (ADA) Seal of Acceptance Program and Product Evaluations. The ADA's Council on Scientific Affairs has independently reviewed data on the safety and effectiveness of triclosan /copolymer for reducing cavities, plaque and gingivitis. The council concluded that there were sufficient clinical studies that showed these toothpastes reduced the incidence of cavities, the presence of plaque and gingivitis.

Most of the studies of toothpastes evaluated in the Cochrane report were directly or indirectly supported by companies that make toothpaste. Only three studies appeared to be independent, according to the reviewers. The independent or government-funded research community and industry should work together to research antibacterial agents in toothpastes, Riley noted. "But we would argue for complete independent control of the research, including study design, conducting the study, and ownership of the data."

Study Examines Treatment Responses in TMD Patients

Tempromandibular pain disorders (TMDs) are characterized by a dysfunction of the TMD joint and cause orofacial pain, masticatory dysfunction or both. A new study published in The Journal of Pain showed that standard treatment approaches yield modest to large improvement in pain, but the addition of cognitive behavioral therapy may be helpful. The Journal of Pain is published by the American Pain Society, www.americanpainsociety.org.

Some 10 to 36 million U.S. adults, primarily women, have TMD pain, making this condition the second most frequent pain disorder following low-back pain. MD pain usually can be managed with conservative treatment with non-steroidal anti-inflammatory pain medications (NSAIDS), supportive patient education, diet modifications and an intraoral splint and/or occlusal therapy. Not all patients benefit, however, and previous research has shown that many TMD patients benefit from cognitive behavioral therapy (CBT). But the reasons behind CBT treatment success or failure are unclear.

Researchers from the University of Connecticut Health Center evaluated 101 TMD patients on a daily basis for three months. Study subjects reported having TMD pain for an average of 6.7 years. They were randomly assigned to one of two treatment groups: standard conservative care and standard care with CBT added, which included coping skills training. The purpose of the study was to determine if specific subtypes of treatment nonresponsive TMD patients could be identified to determine if CBT could be helpful.

The authors hypothesized that certain CBT treatment-related outcomes, such as lower retention in treatment and less adaptive changes in coping, self efficacy and catastrophizing, might be predictive of treatment non-response.

Results showed that nonresponders scored higher on depression scores, exhibited lower self efficacy and coping ability, and catastrophized more than more adaptive patients. It was noted that nonresponsive patients did not show more joint pathology than patients who responded well to treatment. Despite lack of joint pathology, the nonresponsive subjects were more likely to report being disabled by their TMD pain.

The study concluded it is important to recognize the importance of the heterogeneous nature of TMD pain, and that treating TMD patients as a homogeneous group is likely to result in suboptimal therapy for many patients. Even though no treatment is successful for all TMD patients, certain psychosocial factors can make some patients unresponsive to CBT.

Buck Teeth: Correct Them Once In Early Adolescence

Courtesy of Health Behavior News Service, part of the Center for Advancing Health

KEY POINTS

* A review finds few benefits to a two-stage orthodontic correction for buck teeth in children versus treatment done in one-stage during early adolescence.__* A two stage correction requires treatment over a longer period of time, which typically increases the cost.

Newswise — Children with prominent front teeth, colloquially known as buck teeth, often require orthodontic work to straighten their teeth and improve both their bite and appearance. This can be done in one stage during early adolescence (age 10 to 16) or two stages with the first stage between age 7 and 11 and the second in early adolescence. A new Cochrane review finds few benefits to the two-stage correction.

Upper front teeth that stick out are more likely to be broken or knocked out in an accident. In addition, their appearance can lead to a child being made fun of or being bullied. But orthodontists, parents, and children are faced with deciding whether to treat in two stages, early and late, or in just one later stage.

The research team analyzed data from 17 randomized controlled trials of children treated for Class II malocclusion, which is one cause of prominent front teeth. The trials included 721 children.

They concluded that providing treatment early slightly reduced the risk of a child damaging their front teeth if they had an accident while playing or participating in sports, but offered few other benefits. "There was no other benefit for having treatment early, age 8, as opposed to having treatment during adolescent age," according to Kevin O'Brien, professor of orthodontics at the University of Manchester in England.

"The results of this review will provide information to allow the orthodontist to explain fully the potential risks of not having treatment when the child is 8 years old," O'Brien stated. This can help orthodontists, parents and their children make an informed decision, he said.

The study also looked at evaluations of several types of orthodontic braces and appliances, including fixed and removable devices and head-braces. One type, the Twin-Block, was shown to be more effective in reducing the protrusion of the upper front teeth at an early age.

There is no official standard of care when it comes to treating prominent front teeth, David L. Turpin, D.D.S., Moore/Riedel Professor in the department of orthodontics at the University of Washington School of Dentistry in Seattle. "Teeth come in all types of bite and jaw relationships and children come in all shapes and sizes," he said. "Orthodontists should know all the different ramifications and should be good at treating problems in differing ways to meet the child's needs."

"In general, the earlier that treatment starts the longer it lasts, which in turn increases the cost," Turpin said.

TERMS OF USE: This story is protected by copyright. When reproducing any material, including interview excerpts, attribution to the Health Behavior News Service, part of the Center for Advancing Health,

Junk food and poor oral health increase risk of premature heart disease

The association between poor oral health and increased risk of cardiovascular disease should make the reduction of sugars such as those contained in junk food, particularly fizzy drinks, an important health policy target, say experts writing in the Journal of the Royal Society of Medicine. Poor oral hygiene and excess sugar consumption can lead to periodontal disease where the supporting bone around the teeth is destroyed. It is thought that chronic infection from gum disease can trigger an inflammatory response that leads to heart disease through a process called atherosclerosis, or hardening of the arteries. Despite convincing evidence linking poor oral health to premature heart disease, the most recent UK national guidance on the prevention of CVD at population level mentions the reduction of sugar only indirectly.

Dr Ahmed Rashid, Department of Public Health and Primary Care, University of Cambridge, who co-wrote the paper, said: "As well as having high levels of fats and salt, junk foods often contain a great deal of sugar and the effect this has on oral health may be an important additional mechanism by which junk food elevates risk of CVD." He added: "Among different types of junk food, soft drinks have raised particular concerns and are the main source of free sugar for many individuals." The authors refer to the well-publicised New York 'soda ban' controversy which has brought the issue to the attention of many. Yet, they point out, in the UK fizzy drinks remain commonly available in public areas ranging from hospitals to schools. Dr Rashid said: "The UK population should be encouraged to reduce fizzy drink intake and improve oral hygiene. Reducing sugar consumption and managing dental problems early could help prevent heart problems later in life."

Brushing your teeth could prevent heart disease

Prospective study finds clinically significant difference in atherosclerosis progression based on changes in periodontal health

Taking care of your gums by brushing, flossing, and regular dental visits could help hold heart disease at bay. Researchers at Columbia University's Mailman School of Public Health have shown for the first time that as gum health improves, progression of atherosclerosis slows to a clinically significant degree. Findings appear online in the Journal of the American Heart Association.

Artherosclerosis, or the narrowing of arteries through the build-up of plaque, is a major risk factor for heart disease, stroke, and death.

"These results are important because atherosclerosis progressed in parallel with both clinical periodontal disease and the bacterial profiles in the gums. This is the most direct evidence yet that modifying the periodontal bacterial profile could play a role in preventing or slowing both diseases," says Moïse Desvarieux, MD, PhD, lead author of the paper and associate professor of Epidemiology at the Mailman School.

The researchers followed 420 adults as part of the Oral Infections and Vascular Disease Epidemiology Study (INVEST), a randomly sampled prospective cohort of Northern Manhattan residents. Participants were examined for periodontal infection. Overall, 5,008 plaque samples were taken from several teeth, beneath the gum, and analyzed for 11 bacterial strains linked to periodontal disease and seven control bacteria. Fluid around the gums was sampled to assess levels of Interleukin-1β, a marker of inflammation. Atherosclerosis in both carotid arteries was measured using high-resolution ultrasound.

Over a median follow-up period of three years, the researchers found that improvement in periodontal health—health of the gums—and a reduction in the proportion of specific bacteria linked to periodontal disease correlated to a slower intima-medial thickness (IMT) progression, and worsening periodontal infections paralleled the progression of IMT. Results were adjusted for potential confounders such as body mass index, cholesterol levels, diabetes, and smoking status,

Clinical Significance

There was a 0.1 mm difference in IMT change over three years among study participants whose periodontal health was deteriorating compared with those whose periodontal health was improving. Previous research has shown that a .033 mm/year increase in carotid IMT (equivalent to approximately 0.1 mm over three years) is associated with a 2.3-fold increased risk for coronary events.

"When it comes to atherosclerosis, a tenth of a millimeter in the thickness of the carotid artery is a big deal. Based on prior research, it appears to meet the threshold of clinical significance," says Tatjana Rundek, MD, PhD, a co-author of the study and professor at the University of Miami whose lab read the carotid ultrasounds.

Even subtle changes to periodontal status had a dose-response relationship to carotid IMT. "Our results show a clear relationship between what is happening in the mouth and thickening of the carotid artery, even before the onset of full-fledged periodontal disease," says co-author Panos N. Papapanou, DDS, PhD, professor of Dental Medicine at Columbia University's College of Dental Medicine, whose laboratory assessed the bacterial profiles in the gums. "This suggests that incipient periodontal disease should not be ignored."

Bacteria in the mouth may contribute to the onset of atherosclerosis in a number of ways, scientists speculate. Animal studies indicate that they may trigger immune response and high levels of inflammatory markers, which may initiate or exacerbate the inflammatory aspect of atherosclerosis.

The results build on previous findings. In earlier cross-sectional results, Dr. Desvarieux and colleagues had reported that higher levels of disease-causing bacteria were associated with thicker IMT. The current study takes the next step by looking at the cohort over time.

"Our results address a gap identified in the AHA statement on periodontal disease and atherosclerosis, by providing longitudinal data supporting this association," says study co-author Ralph Sacco, MD, professor and chairman of Neurology at the University of Miami, Miller School of Medicine and former president of the American Heart Association. Concludes Dr. Desvarieux, "It is critical that we continue to follow these patients to see if the relationship between periodontal infections and atherosclerosis carries over to clinical events like heart attack and stroke and test if modifying the periodontal flora will slow the progression of atherosclerosis."

Burning Mouth Syndrome Is Often Difficult to Diagnose

Oral pain that feels like a scalded mouth and can last for months has baffled dental researchers since the 1970s, when burning oral sensations were linked to mucosal, periodontal, and restorative disorders and mental or emotional causes.

It’s called burning mouth syndrome (BMS), and it’s gaining the attention of such dental researchers as oral pain expert Andres Pinto, who recently joined Case Western Reserve University’s School of Dental Medicine faculty.

What’s frustrates patients and doctors alike, said Pinto, is that the mouth and gums appear normal with BMS, so its diagnosis is difficult. Patients often find themselves having to visit several doctors before finally arriving at BMS as the cause.

Pinto, new chair and associate professor in the Department of Oral Diagnosis and Radiology at the dental school and an oral medical specialist in the Department of Oral and Maxillofacial Surgery at UH Case Medical Center, encourages people with persistent mouth pain to check for the following symptoms that might be caused by BMS:

• Persistent burning tongue and oral pain with no apparent dental cause
• Abnormal taste or dry feeling in the mouth
• Symptoms that disappear when eating
• Burning sensations may migrate across several oral areas

Even if oral pain is present without these symptoms, Pinto recommended consulting a dentist for a thorough exam of the teeth, gums, mouth and throat.

Between two and five percent of the U.S. population acquires BMS, he said, but the syndrome especially strikes women between age 50 and 70, and from three years before to 12 years after menopause.

Early research in BMS explored the association with local oral changes that could be corrected by dentists, and the observed comorbidity with psychogenic disorders. Changes in neurologic sensory function in patients with BMS and reported cases of secondary BMS to anemia, diabetes, vitamin deficiency, and thyroid disorders, triggered further exploration into peripheral neural changes and central nervous system (brain) mechanisms that could contribute to the causes of this condition.

Although the exact cause of BMS is unknown, the suspected origin is deterioration of the nerves beneath the oral lining. The deterioration isn’t visible, which explains why the mouth appears normal when examined and can delay diagnosis, Pinto explained. Still unproven is the role hormones may play in BMS, given the link to menopause.

The pain from BMS often results in quality of life issues, from poor nutrition to the sufferer withdrawing from social situations. In some cases, the pain is so severe it has driven people to commit suicide, Pinto said.

Patients can receive relief with special mouthwashes, analgesics and other topical and systemic treatments.

Pinto recently joined a research team to learn what postgraduate programs in dental schools are teaching about BMS. The researchers report in the October issue of the Journal of the American Dental Association that BMS is being taught but more needs to be done.