Jaw Functional Limitation Research Articles

Association of Oral Behaviors with Anxiety, Depression, and Jaw Function in Patients with Temporomandibular Disorders in China: A Cross-Sectional Study.

BackgroundThe aim of this study was to investigate the association of oral behaviors (OBs) with anxiety, depression, and jaw function in patients with temporomandibular disorders (TMDs) in China.Material/MethodsA total of 537 patients diagnosed with TMD were included in this study (average age, 31.5512.08 years; 86 men [16.0%] and 451 women [84.0%]). There were 31 cases of masticatory muscle pain, 459 cases of disc displacement, and 13 cases of arthralgia/arthrosis, and 34 cases were uncategorized. Patients were assessed using the Oral Behaviors Checklist (OBC), Jaw Functional Limitation Scale (JFLS), Generalized Anxiety Disorder-7 (GAD-7) scale, and Patient Health Questionnaire-9 (PHQ-9). The relationships between OBC scores and mouth opening, pain scores, JFLS, PHQ-9, and GAD-7 were evaluated with Spearmans correlation analysis. The median TMD symptom duration was 3 (0.5154) months; men and women did not differ significantly in symptom duration or in the number of episodes of depression and anxiety.ResultsThe following OBs were common in patients with TMDs: putting pressure on the jaw (52.9%), chewing food on 1 side (47.5%), and holding teeth together during activities other than eating (33.3%). The OBC scores were significantly correlated with the JFLS, PHQ-9, and GAD-7 scores (P<0.01).ConclusionsPatients with TMDs exhibit specific OBs, which are associated with depression, anxiety, and jaw function. It is necessary to further investigate the interaction of OBs with depression and anxiety in the development of TMDs.

Impact of Fibromyalgia Phenotype in Temporomandibular Disorders.

Mounting evidence suggests that central nervous system amplification, similar to that seen in fibromyalgia (FM), contributes to the pain experience in a subset of patients with temporomandibular disorders (TMD). In this prospective observational study, patients with TMD completed the 2011 FM survey questionnaire, a surrogate measure of "centralized" pain. The influence of centralized pain on TMD pain, dysfunction, and disability was assessed dichotomously by determining the incidence of FM-positive cases in the sample and by using FM survey scores as a continuous measure of "fibromyalgia-ness" ("FM-ness"). The patients meeting criteria for FM diagnosis (17 of 89) had significantly more disease burden on numerous measures. FM-ness was positively associated with pain at rest, negative mood, tenderness to palpation, perceived jaw functional limitation, and pain-related disability, and it was negatively associated with comfortable pain-free jaw opening. The impact of FM-ness on perceived jaw functional limitation and disability was mediated by levels of spontaneous, ongoing pain in the orofacial region. Importantly, this pattern of findings was still present even in those not meeting the criteria for FM diagnosis. Together, these results imply that higher FM-ness increases TMD patient burden by amplifying spontaneous pain and further hampering painless jaw function, even in patients who do not meet criteria for FM diagnosis. These results are highly relevant for the clinical management of TMD, as they imply that targeting the central nervous system in the treatment of patients with TMD with evidence of pain centralization may help ameliorate both pain and jaw dysfunction.

The Impact of Education and Physical Therapy on Oral Behaviour in Patients with Temporomandibular Disorder: A Preliminary Study.

Patient education is important in the treatment of temporomandibular disorder (TMD), but little is known about its effect on oral behaviors. We aimed to determine the dominant oral behaviours in patients with TMD and assess the impact of education on such behaviours. Between July 2018 and April 2019, 54 patients diagnosed with TMD according to DC/TMD were recruited. They received physical therapy and were provided education on TMD and offered a list of recommendations for improving their oral behaviours. The patient education process usually lasted for 10–20 min. Of these patients, 48 were reexamined at the outpatient clinic, 3–9 months posttreatment. We recorded the Oral Behaviour Checklist (OBC) score, maximum painless mouth opening (mm), visual analogue scale (VAS) score for pain, and Jaw Functional Limitation Scale (JFLS) score pre- and posttreatment. Wilcoxon signed rank test and paired sample t-test were used for statistical analysis. Results showed that the most dominant oral behaviours included “putting pressure on the jaw” (59.3%); “chewing food on one side” (46.3%); “pressing, touching, or holding teeth together at times other than eating” (33.3%); and “eating between meals” (33.3%). Posttreatment, the patients reported a decrease in “chewing gum” (P = 0.002), “leaning with the hand on the jaw” (P = 0.013), “chewing food on one side” (P ≤ 0.001), and “eating between meals” (P = 0.007), but this change was not significant in subgroups with a follow-up interval of 9 months. We also observed a significant improvement in the maximum painless mouth opening (P ≤ 0.001), JFLS score (P ≤ 0.001), and VAS score (P ≤ 0.001) for pain, posttreatment. In conclusion, patient education can facilitate management of oral behaviours and should be targeted towards specific oral behaviours.

The effect of the ischaemic compression technique on pain and functionality in temporomandibular disorders: A randomised clinical trial.

Interventions addressing pain and impaired functionality in individuals with temporomandibular disorders (TMDs) are needed. To compare the effects of 4weeks of exercise combined with ischaemic compression and exercise alone in patients with TMDs. Fifty patients who were diagnosed with TMDs were randomised into Group 1 (exercise combined with ischaemic compression technique) (n=25) or Group 2 (exercise alone) (n=25). Both groups performed 4weeks of Rocabado's exercise and 3weeks of postural exercise, while Group 1 received ischaemic compression to the masseter muscle for a total of 3 sessions in addition to exercise. A ruler was used to assess range of motion (ROM) (painless mouth opening (PMO), maximum mouth opening, maximum assisted mouth opening (MAMO), left lateral movement and right lateral movement), the visual analogue scale and graded chronic pain scale were used to assess pain, an algometer was used to determine the pain pressure threshold (PPT), and the 8-item jaw functional limitation scale was used to assess, functionality. The assessments were performed at baseline, at week 1 and at week 4. The participants in Group 1 exhibited larger PMO (F=5.26, P=.02) and MAMO values (F=6.71, P=.01) than did the patients in Group 2 at week 1. The effect size was small for MAMO (ES=0.27) and moderate for PMO (ES=0.51). However, there were no significant differences in any other outcomes between groups at week 1 or 4. In summary, this randomised controlled trial indicates that exercise combined with ICT and exercise alone have similar effects on ROM, pain, the PPT and functionality in patients with TMDs.

"RA.DI.CA." Splint for the Management of the Mandibular Functional Limitation: A Retrospective Study on Patients with Anterior Disc Displacement without Reduction.

The study aimed at assessing the effectiveness of the RA.DI.CA. splint in the management of temporomandibular joint disc displacement without reduction (ADDwoR) and jaw functional limitation. The authors developed a retrospective clinical study. A total of 2739 medical records were screened. One hundred and forty-one patients with chronic unilateral disc displacement without reduction and jaw limitation, treated with a multifunctional RA.DI.CA. splint, were enrolled. Temporomandibular pain, headache, familiar pain, neck pain, and emotional strain, maximum spontaneous mouth opening, and lateral excursions were evaluated at baseline (T0), after therapy (T1), and during the follow-up (T2). Descriptive statistical analysis was performed. Wilcoxon test assessed changes in symptomatology and functional aspects before and after treatment and between T1 and T2, with p < 0.05. Ninety-nine patients (70%) declared themselves “healed” from jaw functional limitation with no residual painful symptoms, 31 (22%) improved their symptoms and jaw function, 11 (8%) reported no changes compared to T0 and no one worsened. As for all parameters analyzed, the comparison between the ones before and after treatment was statistically significant (p < 0.05). The RA.DI.CA. splint proved to be highly performing and promoting functional and symptomatologic recovery, also in the medium and long term, through the restoration of the functional disc-condyle relationship and the healing of joint tissues.

To what extent are the characteristics of painful temporomandibular disorders predictors of self-reported limitations in jaw function?

ABSTRACT Objective: The study evaluated the extent to which the source, intensity, and duration of temporomandibular disorder (TMD) pain are predictors of limitations in jaw function. Methods: The sample included 166 subjects (12–69 years) who self-administered the Jaw Function Limitation Scale (JFLS) and underwent clinical examinations. Results: In univariate correlations, global limitation (long-form JFLS) as well as mastication, mobility, and communication had the highest correlation with headache attributed to TMD (r = 0.362–0.415; p < 0.001). Correlation was higher for pain intensity than chronicity. In multiple regression analysis, significant predictors of jaw limitations (long-form JFLS) were only headache and increasing age (p < 0.001), when controlling for demographic variables, the characteristics of pain, source of pain, and presence of intraarticular disorders. Discussion: Limitation in jaw function is influenced more by pain than by the intracapsular condition and even more so by pain intensity than chronicity.

Comparison of Pain-Generated Functional Outcomes in Experimental Models of Delayed-Onset Muscle Soreness and Nerve Growth Factor Injection of the Masticatory Muscles.

To compare two pain models of myalgic TMD, delayed-onset muscle soreness (DOMS) and injections of nerve growth factor (NGF), in terms of pain-related and motor function outcomes, as well as activity-related temporal summation. Fifty age- and gender-matched healthy participants were recruited and randomized into one of three groups: to a repeated eccentric contraction task to cause DOMS (n = 20), to receive NGF injections into the masseter muscle (n = 20), or to a control group (n = 10). Mechanical sensitivity of masticatory muscles, chewing parameters, jaw function limitation, maximum bite force, and activity-related temporal summation were assessed at baseline and at days 1, 2, and 7 following the intervention. Compared to baseline, both model groups showed increased mechanical sensitivity, jaw function limitation, pain on chewing, and decreased chewing efficiency, lasting longer in the NGF group than in the DOMS group (P < .05). Furthermore, also compared to baseline, the NGF group showed increased pain on maximum bite and decreased pain-free maximum opening (P < .05). No increases in activity-related temporal summation were shown for any of the model groups when compared to baseline or the control group (P > .05). Both models produced similar pain-related outcomes, with the NGF model having a longer effect. Furthermore, the NGF model showed a more substantial effect on motor function, which was not seen for the DOMS model. Finally, neither of the models were able to provoke activity-related temporal summation of pain.

Effect of Therapeutic Jaw Exercises in the Treatment of Masticatory Myofascial Pain: A Randomized Controlled Study.

To study the effect and cost-effectiveness of jaw exercise treatment in patients with masticatory myofascial pain. A total of 97 patients with myofascial pain according to the RDC/TMD were randomized into three groups: (1) jaw exercises; (2) stabilization appliance; or (3) no treatment. After 3 months, the patients were evaluated according to the following instruments: pain intensity according to a visual analog scale (VAS); global improvement according to the Patient Global Impression of Change scale (PGIC); depression and anxiety according to the Hospital Anxiety and Depression Scale (HADS); jaw function according to the Jaw Functional Limitation Scale (JFLS-20); consumption of analgesics; and frequency of tension-type headache. Pain intensity during jaw movement decreased significantly more in the jaw exercise group compared to the no treatment group (P < .001). There was no statistically significant difference between the jaw exercise and stabilization appliance groups in this aspect. The patients in the treatment groups reported greater improvement on the PGIC compared to the no treatment group (P < .001). There was a significant decrease in headache frequency (P = .028), consumption of analgesics (P = .007), and JFLS scores (P = .008) in the jaw exercise group compared to the no treatment group. In the jaw exercise group, patients had fewer appointments and a lower mean treatment time compared to the group that received stabilization appliance treatment. Jaw exercises are effective in reducing pain intensity, headache, and consumption of analgesics in patients with masticatory myofascial pain. Jaw exercises are also cost-effective when compared to treatment with a stabilization appliance.

Translation and Adaptation of the Diagnostic Criteria for Temporomandibular Disorders into the Malay Language: Psychometric Evaluation of Contents.

To develop the Malay DC/TMD through a formal cross-cultural adaptation (CCA) process for use in non-English speaking populations and to determine the reliability and validity of the Malay Graded Chronic Pain Scale (M-GCPS) and Malay Jaw Functional Limitation Scale (M-JFLS). The English DC/TMD was translated into the Malay language using the forward-backward translation procedures specified in the INfORM guideline. The initial Malay instrument was pre-tested, and any discrepancies were identified and reconciled before producing the final Malay DC/TMD. Psychometric properties of the M-GCPS and M-JFLS were evaluated using a convenience sample of 252 subjects and were assessed using internal consistency and test-retest reliability, as well as face, content, concurrent, and construct validity testing. Internal consistency was assessed using Cronbach's alpha, while test-retest reliability was examined using intraclass correlation coefficient (ICC). Concurrent and construct validity of both domains were performed using Spearman ρ correlation test. In addition, construct and discriminant validity were appraised using Kruskal-Wallis and Mann-Whitney U tests, respectively. Cronbach's alpha values for the M-GCPS and M-JFLS were 0.95 and 0.97, respectively. The ICC was 0.98 for the M-GCPS and 0.99 for M-JFLS. The majority of the tested associations for both domains were found to be statistically significant, with good positive correlations. The M-GCPS and M-JFLS were found to be reproducible and valid. The Malay DC/TMD shows potential for use among Malay-speaking adults.

Internet-Based Multimodal Pain Program With Telephone Support for Adults With Chronic Temporomandibular Disorder Pain: Randomized Controlled Pilot Trial.

BackgroundChronic pain from temporomandibular disorders remains an undertreated condition with debate regarding the most effective treatment modalities.ObjectiveThe aim of the study was to investigate the treatment effect of an internet-based multimodal pain program on chronic temporomandibular disorder pain and evaluate the feasibility of a larger randomized controlled trial.MethodsAn unblinded randomized controlled pilot trial was conducted with 43 participants (34 females, 9 males; median age 27, IQR 23-37 years) with chronic temporomandibular pain. Participants were recruited within the Public Dental Health Service and randomized to intervention (n=20) or active control (n=23). The intervention comprised a dentist-assisted internet-based multimodal pain program with 7 modules based on cognitive behavior therapy and self-management principles. The control group received conventional occlusal splint therapy. Primary outcomes included characteristic pain intensity, pain-related disability, and jaw functional limitation. Secondary outcomes were depression, anxiety, catastrophizing, and stress. Outcomes were self-assessed through questionnaires sent by mail at 3 and 6 months after treatment start. Feasibility evaluation included testing the study protocol and estimation of recruitment and attrition rates in the current research setting.ResultsOnly 49% of participants (21/43) provided data at the 6-month follow-up (internet-based multimodal pain program: n=7; control: n=14). Of the 20 participants randomized to the internet-based multimodal pain program, 14 started treatment and 8 completed all 7 modules of the program. Between-group analysis showed no significant difference for any outcome measure at 3- or 6-month follow-up—characteristic pain intensity (3 months: P=.58; 6 months: P=.41), pain-related disability (3 months: P=.51; 6 months: P=.12), jaw functional limitation (3 months: P=.45; 6 months: P=.90), degree of depression (3 months: P=.64; 6 months: P=.65), anxiety (3 months: P=.93; 6 months: P=.31), stress (3 months: P=.66; 6 months: P=.74), or catastrophizing (3 months: P=.86; 6 months: P=.85). Within-group analysis in the internet-based multimodal pain program group showed a significant reduction in jaw functional limitation score at the 6-month follow-up compared to baseline (Friedman: χ2=10.2, P=.04; Wilcoxon: z=–2.3, P=.02). In the occlusal splint group, jaw function limitation was also reduced at the 6-month follow-up (Friedman: χ2=20.0, P=.045; Wilcoxon: z=–2.3, P=.02), and there was a reduction in characteristic pain intensity at the 3- and 6-month follow-up (Friedman: χ2=25.1, P=.01; Wilcoxon 3 months: z=–3.0, P=.003; Wilcoxon 6 months: z=-3.3, P=.001).ConclusionsThis study was not able to demonstrate a difference in treatment outcome between an internet-based multimodal pain program and occlusal splint therapy in patients with chronic temporomandibular pain. However, the findings suggested that the internet-based multimodal pain program improves jaw function. The results also confirmed the treatment effect of occlusal splint therapy for chronic temporomandibular pain. Furthermore, because of the high attrition rate, this pilot study showed that a randomized controlled trial with this design is not feasible.Trial RegistrationClinicalTrials.gov NCT04363762; https://clinicaltrials.gov/show/NCT04363762

Comparison of the Efficacy of Botulinum Toxin, Local Anesthesia, and Platelet-Rich Plasma Injections in Patients With Myofascial Trigger Points in the Masseter Muscle

Masticatory myofascial trigger points (TrP) are one of the major causes of nondental pain in the orofacial region. Intramuscular injections are considered the first-line treatment for myofascial TrPs. The objectives of this study were to evaluate and compare the effectiveness of local anesthesia (LA), botulinum toxin (BTX), and platelet-rich plasma (PRP) injections for the treatment of myofascial TrPs in the masseter muscle. In this retrospective study, the sample was composed of patients with myofascial TrPs in masseter muscle who were treated between 2016 and 2019. Patients were divided into 3 groups according to treatment methods: group I (LA injection), group II (BTX injection), and group III (PRP injection). Primary outcome variable was the average pain level at rest and while chewing, and pressure pain intensity (PPI), Jaw Functional Limitation Scale (JFLS) value, and quality-of-life (measured using Oral Health Impact Profile-14 (OHIP-14)) were secondary outcomes. The outcome variables were assessed at diagnosis, and 1, 3, and 6months post-treatment. The study consisted of 82 patients (group I, 27; group II, 26; group III, 29). At 1 and 3months, improvement in all parameters was recorded in all groups. Groups I and II showed superior improvement in all parameters compared with group III at 3months. Improvements in VAS pain, JFLS, and OHIP-14 values were significantly better in group II than group I at 3months (P=.009; P=.004; P=.002). At 6months, significant improvement in VAS pain, JFLS, and OHIP-14 (P=.008; P<.001; P<.01) values was recorded only in group II. All procedures successfully improved the symptoms of TrPs in the masseter muscle at 1 and 3months. However, BTX injection seemed superior at the 3-month follow-up and remained effective up to 6months.

Orofacial Motor Functions and Temporomandibular Disorders in Patients With Sjögren's Syndrome

Sjögren's syndrome (SS) induces difficulty in chewing and swallowing due to low salivary flow. However, these symptoms may be associated with other factors, such as orofacial myofunctional disorders and temporomandibular disorder (TMD), which have not been comprehensively assessed in this population. The aims of this study were to investigate orofacial muscles and functions as well as the presence of TMD in patients with SS compared with a group without SS and to analyze whether the patients' experience of limitations in orofacial functioning is associated with the orofacial functional status and muscle pain related to TMD. Women with SS based on the 2002 American-European Consensus Group criteria and volunteers paired by age and sex were compared. The examinations included the orofacial myofunctional evaluation with scores (OMES) protocol, tongue and lip strength measures, and electromyography of the masticatory muscles. TMD investigations included clinical examination, self-report of symptoms, and assessment according to the Jaw Functional Limitation Scale. Patients with SS present with impaired muscle and orofacial functions based on lower scores of all categories of OMES (P < 0.0001), tongue strength (P = 0.0003-0.0004), and masticatory muscle activity (P = 0.0002-0.007), as well as worse TMD signs and symptoms (P < 0.05) and jaw functional limitation (P < 0.0001-0.0003). Patients' experiences with limitation in mastication and swallowing were associated with orofacial myofunctional status and muscle pain related to TMD. Those disorders should be monitored along with disease control and must be addressed in the clinical evaluation to prevent nutritional and metabolic comorbidities in patients with SS.

Understanding the relationship between features associated with pain-related disability in people with painful temporomandibular disorder: an exploratory structural equation modeling approach.

Pain-related disability is a multifaceted construct that refers to the impact of pain on an individual's capacity to fulfill their self-defined and social roles. This research examined the relationship between clinical, psychological, and pain sensitivity factors and pain-related disability among adults with chronic temporomandibular disorder (TMD). We analyzed data from a cross-sectional community-based sample of 1088 men and women with chronic TMD. We first constructed and tested a measure of pain-related disability (ie, pain impact), including a variable assessing presenteeism, created measurement models of jaw limitation, psychological unease (negative affect, somatic symptoms, and catastrophizing), and experimental pain sensitivity (eg, pressure pain threshold, thermal tolerance, and mechanical pressure pain threshold). Subsequently, latent variables were combined in a structural equation model. Participants (n = 1088) were 18 to 44 years old (mean 29.2, SD ± 7.8) whose chronic TMD had persisted, on average, for 6.9 years (SD ± 6.4). A model of pain-related disability, jaw limitation, and psychological unease was created and refined with exploratory model revisions to account for correlation among variables. Estimation of the final model indicated excellent fit with the data (root-mean-square error of approximation = 0.048, root-mean-square error of approximation 90% confidence interval [CI] 0.043-0.053, comparative fit index = 0.956, standardized root-mean-square residual = 0.040). Jaw functional limitation and psychological unease was strongly related to pain-related disability. Experimental pain sensitivity was removed from our model because of weak direct effect and the burden of performing experimental pain sensitivity testing in a clinical setting. The final model explained 78% of the variance in pain-related disability.

Temporomandibular disorders and cervicogenic dizziness: Relations between cervical range of motion and clinical parameters

ABSTRACT Objective To analyze the cervical range of motion (CROM) and clinical parameters in patients affected by myogenous temporomandibular disorders (TMD), cervicogenic dizziness (CGD), both TMD and CGD (TMD/CGD), and a group of healthy subjects (HS). Methods CROM degrees, Dizziness Handicap Inventory (DHI), Tampa Scale for Kinesiophobia (TSK-17), Hospital Anxiety and Depression Scale (HADS), and Jaw Functional Limitation Scale 20 (JFLS-20) scores were compared between 46 TMD patients, 49 CGD subjects, 43 TMD/CGD patients, and 98 HS. Results TMD/CGD and CGD patients demonstrated significantly lower CROM degrees and higher DHI, TSK-17, and HADS values when compared to TMD patients. TMD/CGD and TMD patients demonstrated higher JFLS-20 values when compared to CGD and HS. Significant negative correlations were found in TMD/CGD and TMD patients between JFLS-20 and CROM in flexion and extension. Discussion Present findings demonstrated a relation between spine movement impairment and TMD.

Efficacy, safety, and economic assessment of hominis placental pharmacopuncture for chronic temporomandibular disorder: a protocol for a multicentre randomised controlled trial

BackgroundTemporomandibular disorder (TMD) is a condition encompassing clinical symptoms of the temporomandibular joint, masseter muscle, and surrounding structures. Hominis placental pharmacopuncture (HPP), consisting of human placental extract, has been reported as effective for treating chronic musculoskeletal disorders, but a lack of well-designed randomised controlled trial s (RCTs) mean there is insufficient evidence to prove the efficacy of HPP.MethodsThis study is a two-arm parallel, assessor-blinded, multi-centre, randomised controlled trial. We will enrol 82 chronic TMD patients from rwo Korean Medicine hospitals in Axis 1, Group I according to RDC/TMD diagnostic criteria, and randomly allocate 41 patients each to an HPP group and a physical therapy (PT) group. Treatment will be administered in 10 rounds, after which there will be four follow-up visits 6, 9, 13, and 25 weeks from baseline. The primary end point is 6 weeks after baseline, and the primary outcome is the difference in Visual Analogue Scale (VAS) score for temporomandibular pain between baseline and week 6. Secondary outcomes will be Numeric Rating Scale (NRS) scores for temporomandibular pain and discomfort, temporomandibular joint range of motion, the Korean version of Beck’s Depression Index-II (K-BDI-II), Jaw Functional Limitation Scale (JFLS), Patient Global Impression of Change (PGIC) scores, and quality of life. Using data on adverse events and cost-effectiveness in the two groups, we will perform a safety assessment and a cost-effectiveness analysis (economic assessment).DiscussionThis study will assess the efficacy and safety of HPP for chronic TMD compared with PT. This RCT will provide evidence for the efficacy, safety, and economics of HPP.Trial registrationclinicaTrials.gov (NCT04087005) / Clinical Research Information Service (CRIS) (KCT0004437) / IRB (JASENG 2017–09–002-002, KHNMCOH 2019–08-002) / Ministry of Food and Drug Safety (No. 31886).

International consensus on the most useful assessments used by physical therapists to evaluate patients with temporomandibular disorders: A Delphi study.

To identify assessment tools used to evaluate patients with temporomandibular disorders (TMD) considered to be clinically most useful by a panel of international experts in TMD physical therapy (PT). A Delphi survey method administered to a panel of international experts in TMD PT was conducted over three rounds from October 2017 to June 2018. The initial contact was made by email. Participation was voluntary. An e-survey, according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), was posted using SurveyMonkey for each round. Percentages of responses were analysed for each question from each round of the Delphi survey administrations. Twenty-three experts (completion rate: 23/25) completed all three rounds of the survey for three clinical test categories: 1) questionnaires, 2) pain screening tools and 3) physical examination tests. The following was the consensus-based decision regarding the identification of the clinically most useful assessments. (1) Four of 9 questionnaires were identified: Jaw Functional Limitation (JFL-8), Mandibular Function Impairment Questionnaire (MFIQ), Tampa Scale for Kinesiophobia for Temporomandibular disorders (TSK/TMD) and the neck disability index (NDI). (2) Three of 8 identified pain screening tests: visual analog scale (VAS), numeric pain rating scale (NRS) and pain during mandibular movements. (3) Eight of 18 identified physical examination tests: physiological temporomandibular joint (TMJ) movements, trigger point (TrP) palpation of the masticatory muscles, TrP palpation away from the masticatory system, accessory movements, articular palpation, noise detection during movement, manual screening of the cervical spine and the Neck Flexor Muscle Endurance Test. After three rounds in this Delphi survey, the results of the most used assessment tools by TMD PT experts were established. They proved to be founded on test construct, test psychometric properties (reliability/validity) and expert preference for test clusters. A concordance with the screening tools of the diagnostic criteria of TMD consortium was noted. Findings may be used to guide policymaking purposes and future diagnostic research.

Improvement of bone-erosive temporomandibular joint (TMJ) abnormalities in adolescents undergoing non-surgical treatment: a longitudinal study.

To investigate the longitudinal changes of the imaging temporomandibular joint (TMJ) characteristics in young patients with TMJ-related symptoms and treated with non-surgical methods. The severity of self-reported symptoms at follow-up was also investigated. A cone beam CT (CBCT)/CT follow-up examination [median follow-up 4.1 (1.3-6.4) years] was performed in 22 patients with erosive TMJ abnormalities [baseline median age 16 (12-18) years]. Imaging characteristics were analyzed and the changes between the examinations were categorized as (A) improvement, (B) no change, or (C) worsening. Severity of follow-up symptoms was evaluated using Jaw Functional Limitation Scale (JFLS-8) and Graded Chronic Pain Scale (Grade 0-IV). Analyses were performed separately for left and right TMJ. Findings at baseline and follow-up were compared using McNemar test to account for dependencies. Changes in proportions of hard tissue findings between examinations were assessed using Wilcoxon signed ranks test. A significant reduction in the proportion of patients with erosive abnormalities was found [59.1%, 95% CI (36.4-79.3) %]. Baseline erosions improved in 9/12 (75%) right and 14/15 (93%) left TMJs. About half repaired; developed an intact cortical outline. Number of joints with osteophytes increased (right: p < 0.04, left: p < 0.003). New osteophytes were mostly found in joints with erosive findings. Low or no limitation of jaw function (Jaw Functional Limitation Scale) was found in 12/22 (55%) and no or low intensity of pain (Graded Chronic Pain Scale Grade 0 or I) in 19/22 (86%) at follow-up. We found a high potential for repair of erosive TMJ abnormalities. However, the patient series was small. The majority of patients assessed their symptom severity at follow-up as low.

Effectiveness of Cervical Spine High-Velocity, Low-Amplitude Thrust Added to Behavioral Education, Soft Tissue Mobilization, and Exercise for People With Temporomandibular Disorder With Myalgia: A Randomized Clinical Trial.

To determine the immediate and short-term effects of adding cervical spine high-velocity, low-amplitude thrust (HVLAT) to behavioral education, soft tissue mobilization, and a home exercise program on pain and dysfunction for people with a primary complaint of temporomandibular disorder (TMD) with myalgia. Randomized clinical trial. Fifty individuals with TMD were randomly assigned to receive cervical HVLAT or sham manipulation for 4 visits over 4 weeks. Participants in both groups received other treatments, including standardized behavioral education, soft tissue mobilization, and a home exercise program. Primary outcomes included maximal mouth opening, the numeric pain-rating scale, the Jaw Functional Limitation Scale (JFLS), the Tampa Scale of Kinesiophobia for TMD (TSK-TMD), and a global rating of change (GROC). Self-report and objective measurements were taken at baseline, immediately after initial treatment, and follow-ups of 1 week and 4 weeks. A 2-by-4 mixed-model analysis of variance was used, with intervention group as the between-subjects factor and time as the within-subject factor. Separate analyses of variance were performed for dependent variables, and the hypothesis of interest was the group-by-time interaction. There was no significant interaction for maximal mouth opening, the numeric pain-rating scale, or secondary measures. There were significant 2-way interactions for the JFLS (d = 0.60) and TSK-TMD (d = 0.80). The HVLAT group had lower fear at 4 weeks and improved jaw function earlier (1 week). The GROC favored the HVLAT group, with significant differences in successful outcomes noted immediately after baseline treatment (thrust, 6/25; sham, 0/25) and at 4 weeks (thrust, 17/25; sham, 10/25). Both groups improved over time; however, differences between groups were small. There were significant differences between groups for the JFLS, TSK-TMD, and GROC. The additive clinical effect of cervical HVLAT to standard care remains unclear for treating TMD. J Orthop Sports Phys Ther 2020;50(8):455-465. Epub 6 Jan 2020. doi:10.2519/jospt.2020.9175.

Cervical Spine Thrust Joint Manipulation, Education, and a Home Exercise Program for the Management of Individuals with Temporomandibular Disorder: A Prospective Case Series

Background and Purpose: Temporomandibular disorder (TMD) often leads to chronic pain and disability. Current evidence supporting potentially effective physical therapy (PT) intervention in TMD is limited, however, some support exists for manual therapy, education, and exercise. The purpose of this case series was to describe outcomes in participants with TMD treated with cervical spine manual therapy, education, and exercise. Methods: Five participants (mean symptom duration 2.2 years) with TMD were treated with atlanto-occipital and C2-3 cervical spine thrust joint manipulation (TJM), behavioral education, and a home exercise program for 3 visits over 4 weeks. Primary outcomes included jaw range of motion (ROM), Numeric Pain Rating Scale, Jaw Functional Limitation Scale, and Global Rating of Change (GROC). Secondary measures included pain pressure threshold (PPT), Neck Disability Index, TMD Disability Index, and cervical ROM. Results: Clinically meaningful change was noted in cervical and jaw ROM. Three of five participants (60%) reported symptoms at least “moderately better” (≥ 4 GROC) at 4-weeks. No adverse events were reported. Clinical Relevance: All participants had at least 1 year duration of pain indicating spontaneous recovery was unlikely. While cause and effect relationships cannot be determined, outcomes indicate the approach may be effective. Conclusion: Cervical spine TJM added to education and exercise over three visits may be effective in the chronic TMD population. Future randomized clinical trials are necessary to draw specific conclusions

Validation of a Chinese version of the Jaw Functional Limitation Scale in relation to the diagnostic subgroup of temporomandibular disorders.

Oro-facial function is usually impaired by temporomandibular disorders (TMDs). Several studies on TMDs have used the Jaw Functional Limitation Scale (JFLS) to assess mandibular dysfunction. However, it was originally created in English and hence needs to be validated for use among Chinese people. To develop a Chinese version of the JFLS for Chinese TMD patients and to investigate the validity and reliability of the scale. Content validity and temporal stability were evaluated at two different occasions. The reliability and validity of the JFLS were tested in 483 TMD patients. Cronbach's alpha coefficient and split-half reliability were used to assess internal consistency, while the validity was evaluated by factor analysis. Three factors were extracted during exploratory factor analysis, accounting for 62.39% of the variance. The three-factor model was then measured using confirmatory factor analysis (χ2 /df=3.6, root mean square error of approximation=0.091, comparative fit index=0.896). Internal (coefficient alpha values of .906 for all items and Guttman split-half reliability of 0.756) and test-retest (intra-class correlation coefficient=.851-.897, 95% confidence interval=0.656-0.950) reliabilities were excellent. The Chinese version of the JFLS is reliable and valid for use in Chinese TMD patients.