The importance of complementary exams for the diagnosis of temporomandibular joint disorders

Abstract

First of all, it was a great honor to have our work mentioned by Prof. Charles Greene and Prof. Richard Ohrbach given the relevance of their names in the field of temporomandibular disorders (TMD) and, especially, in connection with the development of Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), the only available tool for research on TMD.We know that RDC/TMD stemmed from the need to establish criteria for standardizing TMD research. To pursue such a goal was a laudable initiative of the authors,1Dworkin S.F. LeResche L. Research diagnostic criteria for temporomandibular disorders.J Craniomandib Disord. 1992; 6: 301-355PubMed Google Scholar for it enabled the studies on the subject to be conducted according to the same method anywhere in the world.For this very reason and realizing its importance, we set out to evaluate the accuracy of RDC/TMD for diagnosing TMJ internal derangements with the sole intent to identify the points that could make it a more accurate tool. The points had already been detected by the authors of the method and its Validation Project, as yet not official.2Schiffman E.L. Truelove E.L. Ohrbach R. et al.Assessment of the validity of the research diagnostic criteria for temporomandibular disorders: I: overview and methodology.J Orofacial Pain. 2010; 24: 7-24PubMed Google Scholar, 3Truelove E. Pan W. Look J.O. et al.The research diagnostic criteria for temporomandibular disorders. III: validity of axis I diagnoses.J Orofacial Pain. 2010; 24: 35-47PubMed Google Scholar, 4Schiffman E.L. Ohrbach R. Truelove E.L. et al.The research diagnostic criteria for temporomandibular disorders. V: methods used to establish and validate revised axis I diagnostic algorithms.J Orofacial Pain. 2010; 24: 63-78PubMed Google Scholar, 5Anderson G.C. Gonzalez Y.M. Ohrbach R. et al.The research diagnostic criteria for temporomandibular disorders VI: future directions.J Orofac Pain. 2010; 24: 79-88PubMed Google ScholarFor example, we performed an analysis of our patients concomitant with the application of RDC/TMD according to the instructions in effect1Dworkin S.F. LeResche L. Research diagnostic criteria for temporomandibular disorders.J Craniomandib Disord. 1992; 6: 301-355PubMed Google Scholar (Figure 1) and another where we palpated the bilaminar zone reaching it not through the auditory meatus (Figure 2) so as to avoid interference from the tissues located between that region and the digital pulp (Figure 3). Such an analysis was carried out with the patient's mouth ajar and the examiner directly palpating the bilaminar zone, which provided us with answers closer to the clinical reality reported by the patient (data still unpublished).Fig. 2External palpation of posterior attachment.View Large Image Figure ViewerDownload (PPT)Fig. 3Interference area – photo: Prof. Edson Aparecido Liberti.View Large Image Figure ViewerDownload (PPT)We believe imaging should remain a complement to the clinical exam at this point, even though it produces visually perfect images (as in 3 dimensional reconstructions).6Mori H. Horiuchi S. Nishimura S. et al.Three-dimensional finite element analysis of cartilaginous tissues in human temporomandibular joint during prolonged clenching.Arch Oral Biol. 2010; 55: 879-886Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Such images, which result from algorithms that reconstruct the site volumetrically, undoubtedly aid in the comprehension of internal derangements, yet do not represent the real case with precision. Images in the hands of an experienced clinician may be of great value to understand joint disorders, but the clinical exam still reigns supreme; thus, the need for a most accurate clinical instrument. The absence of imaging problems may not represent an actual lack of joint dysfunctions. On the other hand, changes detected in the images may show the occurrence of alterations in the joint, but these do not produce clinical symptoms for the patient is undergoing an adaptive process.7Kwang-Joon K. List T. Petersson A. Rohlin M. Relationship between clinical and magnetic resonance imaging diagnoses and findings in degenerative and inflammatory temporomandibular joint diseases: a systematic literature review.J Orofac Pain. 2009; 23: 123-139PubMed Google ScholarIn the specific case of disk displacement, we agree it may only represent the body's adaptation to certain conditions, for despite noticeable signs, most individuals do not complain about symptoms.However, we believe identifying a disk displacement is critical, even at the initial assessment phase, because it is a joint dysfunction, which, in a few cases, can potentially get worse and culminate in a degenerative joint disease (DJD). Like Kwang-Joon et al.,7Kwang-Joon K. List T. Petersson A. Rohlin M. Relationship between clinical and magnetic resonance imaging diagnoses and findings in degenerative and inflammatory temporomandibular joint diseases: a systematic literature review.J Orofac Pain. 2009; 23: 123-139PubMed Google Scholar we think locating the disk through magnetic resonance imaging (MRI) is something that must be done if the treatment plan hinges on such evidence.From the standpoint of research, we believe detecting and classifying joint dysfunctions is important; thus the relevance of RDC/TMD. Conducting research according to standard procedures allows the data from such studies to be compared, providing epidemiological evidence from multicenter trials for the type and degree of joint disorder. Technological advances lead to strides in health care, which meet the needs of a population that shows a worldwide tendency toward aging. Few people, however, have access to such advances. An instance of this is the magnetic resonance (MR) equipment we used. In our country, there are few machines as potent as the one used in our study and they are available only in large centers. We used it to make a difference, since there are few studies assessing TMJ with a 3.0 T, and this, from our viewpoint, precisely shows the development of tools as an aid in clinical practice, but never as a substitute for it.We definitely agree that cases of pain deserve treatment independent from disk conditions but in accordance with imaging exams. We also think that improved imaging might make some professionals dependent on it, inclined to base their decisions on the images. We are thoroughly opposed to such an outcome, because false-positives for disk displacement using MR are a real possibility,8Manfredini D. Guarda-Nardini L. Agreement between research diagnostic criteria for temporomandibular disorders and magnetic resonance diagnoses of temporomandibular disc displacement in a patient population.Int J Oral Maxillofac Surg. 2008; 37: 612-616Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar and, in the case of joint crepitation, it is possible images do not necessarily represent such a clinical feature.9Schmitter M. Essig M. Seneadza V. Balke Z. Schröder J. Rammelsberg P. Prevalence of clinical and radiographic signs of osteoarthrosis of the temporomandibular joint in an older persons community.Dentomaxillofac Radiol. 2010; 39: 231-234Crossref PubMed Scopus (50) Google ScholarIn short, it seems we have a point in common with such distinguished authors, besides Petersson,10Petersson A. What you can and cannot see in TMJ imaging: an overview related to the RDC/TMD diagnostic system.J Oral Rehabil. 2010; 37: 771-778Crossref PubMed Scopus (97) Google Scholar as follows: exams as sophisticated as MR should only be done if they strongly affect diagnosis and treatment, which again stresses the importance of an accurate method of clinical analysis.We would still like to stress that our main conclusion was that RDC/TMD is a good tool to use in carrying out research (and it was designed with this in mind), but owing to the possibility of false-positives in the detection of joint disorders, it must be used with great care in clinical practice. This caveat was also made by Anderson et al.5Anderson G.C. Gonzalez Y.M. Ohrbach R. et al.The research diagnostic criteria for temporomandibular disorders VI: future directions.J Orofac Pain. 2010; 24: 79-88PubMed Google Scholar when they stated that the objective of a classification system, besides aiding research, is to be useful in clinical practice. First of all, it was a great honor to have our work mentioned by Prof. Charles Greene and Prof. Richard Ohrbach given the relevance of their names in the field of temporomandibular disorders (TMD) and, especially, in connection with the development of Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), the only available tool for research on TMD. We know that RDC/TMD stemmed from the need to establish criteria for standardizing TMD research. To pursue such a goal was a laudable initiative of the authors,1Dworkin S.F. LeResche L. Research diagnostic criteria for temporomandibular disorders.J Craniomandib Disord. 1992; 6: 301-355PubMed Google Scholar for it enabled the studies on the subject to be conducted according to the same method anywhere in the world. For this very reason and realizing its importance, we set out to evaluate the accuracy of RDC/TMD for diagnosing TMJ internal derangements with the sole intent to identify the points that could make it a more accurate tool. The points had already been detected by the authors of the method and its Validation Project, as yet not official.2Schiffman E.L. Truelove E.L. Ohrbach R. et al.Assessment of the validity of the research diagnostic criteria for temporomandibular disorders: I: overview and methodology.J Orofacial Pain. 2010; 24: 7-24PubMed Google Scholar, 3Truelove E. Pan W. Look J.O. et al.The research diagnostic criteria for temporomandibular disorders. III: validity of axis I diagnoses.J Orofacial Pain. 2010; 24: 35-47PubMed Google Scholar, 4Schiffman E.L. Ohrbach R. Truelove E.L. et al.The research diagnostic criteria for temporomandibular disorders. V: methods used to establish and validate revised axis I diagnostic algorithms.J Orofacial Pain. 2010; 24: 63-78PubMed Google Scholar, 5Anderson G.C. Gonzalez Y.M. Ohrbach R. et al.The research diagnostic criteria for temporomandibular disorders VI: future directions.J Orofac Pain. 2010; 24: 79-88PubMed Google Scholar For example, we performed an analysis of our patients concomitant with the application of RDC/TMD according to the instructions in effect1Dworkin S.F. LeResche L. Research diagnostic criteria for temporomandibular disorders.J Craniomandib Disord. 1992; 6: 301-355PubMed Google Scholar (Figure 1) and another where we palpated the bilaminar zone reaching it not through the auditory meatus (Figure 2) so as to avoid interference from the tissues located between that region and the digital pulp (Figure 3). Such an analysis was carried out with the patient's mouth ajar and the examiner directly palpating the bilaminar zone, which provided us with answers closer to the clinical reality reported by the patient (data still unpublished). We believe imaging should remain a complement to the clinical exam at this point, even though it produces visually perfect images (as in 3 dimensional reconstructions).6Mori H. Horiuchi S. Nishimura S. et al.Three-dimensional finite element analysis of cartilaginous tissues in human temporomandibular joint during prolonged clenching.Arch Oral Biol. 2010; 55: 879-886Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Such images, which result from algorithms that reconstruct the site volumetrically, undoubtedly aid in the comprehension of internal derangements, yet do not represent the real case with precision. Images in the hands of an experienced clinician may be of great value to understand joint disorders, but the clinical exam still reigns supreme; thus, the need for a most accurate clinical instrument. The absence of imaging problems may not represent an actual lack of joint dysfunctions. On the other hand, changes detected in the images may show the occurrence of alterations in the joint, but these do not produce clinical symptoms for the patient is undergoing an adaptive process.7Kwang-Joon K. List T. Petersson A. Rohlin M. Relationship between clinical and magnetic resonance imaging diagnoses and findings in degenerative and inflammatory temporomandibular joint diseases: a systematic literature review.J Orofac Pain. 2009; 23: 123-139PubMed Google Scholar In the specific case of disk displacement, we agree it may only represent the body's adaptation to certain conditions, for despite noticeable signs, most individuals do not complain about symptoms. However, we believe identifying a disk displacement is critical, even at the initial assessment phase, because it is a joint dysfunction, which, in a few cases, can potentially get worse and culminate in a degenerative joint disease (DJD). Like Kwang-Joon et al.,7Kwang-Joon K. List T. Petersson A. Rohlin M. Relationship between clinical and magnetic resonance imaging diagnoses and findings in degenerative and inflammatory temporomandibular joint diseases: a systematic literature review.J Orofac Pain. 2009; 23: 123-139PubMed Google Scholar we think locating the disk through magnetic resonance imaging (MRI) is something that must be done if the treatment plan hinges on such evidence. From the standpoint of research, we believe detecting and classifying joint dysfunctions is important; thus the relevance of RDC/TMD. Conducting research according to standard procedures allows the data from such studies to be compared, providing epidemiological evidence from multicenter trials for the type and degree of joint disorder. Technological advances lead to strides in health care, which meet the needs of a population that shows a worldwide tendency toward aging. Few people, however, have access to such advances. An instance of this is the magnetic resonance (MR) equipment we used. In our country, there are few machines as potent as the one used in our study and they are available only in large centers. We used it to make a difference, since there are few studies assessing TMJ with a 3.0 T, and this, from our viewpoint, precisely shows the development of tools as an aid in clinical practice, but never as a substitute for it. We definitely agree that cases of pain deserve treatment independent from disk conditions but in accordance with imaging exams. We also think that improved imaging might make some professionals dependent on it, inclined to base their decisions on the images. We are thoroughly opposed to such an outcome, because false-positives for disk displacement using MR are a real possibility,8Manfredini D. Guarda-Nardini L. Agreement between research diagnostic criteria for temporomandibular disorders and magnetic resonance diagnoses of temporomandibular disc displacement in a patient population.Int J Oral Maxillofac Surg. 2008; 37: 612-616Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar and, in the case of joint crepitation, it is possible images do not necessarily represent such a clinical feature.9Schmitter M. Essig M. Seneadza V. Balke Z. Schröder J. Rammelsberg P. Prevalence of clinical and radiographic signs of osteoarthrosis of the temporomandibular joint in an older persons community.Dentomaxillofac Radiol. 2010; 39: 231-234Crossref PubMed Scopus (50) Google Scholar In short, it seems we have a point in common with such distinguished authors, besides Petersson,10Petersson A. What you can and cannot see in TMJ imaging: an overview related to the RDC/TMD diagnostic system.J Oral Rehabil. 2010; 37: 771-778Crossref PubMed Scopus (97) Google Scholar as follows: exams as sophisticated as MR should only be done if they strongly affect diagnosis and treatment, which again stresses the importance of an accurate method of clinical analysis. We would still like to stress that our main conclusion was that RDC/TMD is a good tool to use in carrying out research (and it was designed with this in mind), but owing to the possibility of false-positives in the detection of joint disorders, it must be used with great care in clinical practice. This caveat was also made by Anderson et al.5Anderson G.C. Gonzalez Y.M. Ohrbach R. et al.The research diagnostic criteria for temporomandibular disorders VI: future directions.J Orofac Pain. 2010; 24: 79-88PubMed Google Scholar when they stated that the objective of a classification system, besides aiding research, is to be useful in clinical practice. Temporomandibular joint diagnosis: striking a balance between the sufficiency of clinical assessment and the need for imagingOral Surgery, Oral Medicine, Oral Pathology and Oral RadiologyVol. 116Issue 1PreviewAn interesting evaluation of the validity of the RDC/TMD for the diagnosis of temporomandibular joint (TMJ) internal derangements and degenerative joint disease (DJD) changes was provided by Galhardo and colleagues.1 The authors cited the relevant publications from the RDC/TMD Validation Project,2-4 and appropriately used the imaging diagnosis criteria by Ahmad et al.5 One conclusion by Galhardo et al. is that the RDC/TMD is not valid for internal derangement and DJD diagnoses compared to imaging-based criteria. Full-Text PDF