CAIRNS Et Al-2010-Journal of Oral Rehabilitation

8/18/2019 CAIRNS Et Al-2010-Journal of Oral Rehabilitation

1/9

Commentary

JOR-CORE recommendations on rehabilitation of

temporomandibular disorders

B . C A I R N S * , T . L I S T , A . M I C H E L O T T I , R . O H R BA C H§ & P . S V E NS S O N¶ *Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada, Department of Stomatognathic Physiology, Faculty

of Odontology, Orofacial Pain Unit, Malmö University, Malmö, Sweden, Department of Oral, Dental and Maxillo-Facial Sciences,

Section of Orthodontics and Clinical Gnathology University of Naples Federico II, Naples, Italy, §Department of Oral Diagnostic Sciences,

University at Buffalo, Buffalo, NY, USA and ¶Department of Clinical Oral Physiology, School of Dentistry, Aarhus University, Aarhus C,

Denmark

Introduction

In the long history of temporomandibular disorders

(TMD), the term ’’rehabilitation‘‘ has been often

associated with ’’occlusal rehabilitation‘‘ indicating a

specific philosophy in which occlusion is the crucial

factor for TMD and that intervention on the occlusion

could ’’cure‘‘ the problem. In this paper, the term

rehabilitation is used to denote any medical, physical,

or psychological treatment which brings or restores an

individual to a normal or optimal state of health, and

this revised concept therefore significantly broadens the

scope of rehabilitation of TMD. The purpose of the JOR-

CORE in Siena, 2009 was to critically examine the

current state-of-the-science in the field of TMDs. This

lead to four extensive reviews (1–4) and the present

summaries and recommendations for future research

into rehabilitation of TMDs.

Pathophysiology of TMD

State-of-the-science

The pathophysiology of temporomandibular disorders

(TMD) is complex and involves several mechanisms

discussed in Cairns (1). The principal symptom of TMD

that causes sufferers to seek medical care is pain in the

temporomandibular joint (TMJ) and ⁄ or masticatory

muscles. Degenerative changes in the TMJ likely

underlie pain in only a subgroup of patients with TMD

and consequently there is often a poor correlation

between the severity of pain complaints and patholog-

ical changes in joint and muscle tissues. It has been

demonstrated that some patients with TMD appear to

have altered central nervous system pain processing and

deficits in their ability to recruit endogenous analgesic

mechanisms; collectively, these two central processes

likely contribute to the development of chronic pain in

certain individuals. Recent findings suggest that the

propensity to develop chronic craniofacial pain may also

result from genetic variability that leads to altered levels

of neurotransmitters implicated in the activation and

modulation of pain pathways. Stress reactivity, which

may exert significant modulatory effects on pain

processing, is recognized as an important factor for both

the development and maintenance of pain in TMD and

other chronic pain conditions. There is a greater

prevalence of TMD amongst women, possibly related

to sex hormones and in particular oestrogen, although

how different sex hormones promote (or protect)

against TMD pain is unknown and therefore remains

an area of active research. Unfortunately, the specific

mechanisms that underlie TMD-related pain in the vast

majority of patients with TMD remain enigmatic.

Recommendations

The pathophysiology of TMD and its associated pain

clearly requires a sound foundation of scientific knowl-

edge, particularly with regard to its pathogenesis to

permit the development of more rational and biologi-

cally based approaches to diagnosis and treatment, but

ª 2010 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2010.02082.x

Journal of Oral Rehabilitation 2010 37; 481–489

J o u r n a l o f Oral Rehabilitation


2/9

despite extensive investigations, this has not yet been

achieved. One area of scientific study that might bear

fruit in this regard is the determination of predisposing

factors for the development of TMD. For example, there

are a number of interesting polymorphisms of genes that

have been or may be associated with the development of

chronic pain conditions. Catechol-O-methyl-tranferase

(COMT) is one such gene ⁄ gene product that has received

much attention, while other possible candidates include

serotonin transporters and oestrogen receptors which

need to be characterized further. Other potential ‘bio-

markers’ of TMD pain could include neuropeptides and

neurotransmitters such as calcitonin gene-related pep-

tide (CGRP) and serotonin. Large population-based

prospective studies of patients with TMD and healthy

controls, such as the ‘Orofacial Pain: Prospective Eval-

uation and Risk Assessment’ (OPPERA) study currently

being supported by the National Institute of Dental andCraniofacial Research in the US, will be necessary to

screen for potential markers. Such studies, which focus

on putative risks factors, will also be required not only to

determine whether predictive markers are reliable but

also to define possible mechanisms that regulate ⁄ poten-

tiate pain. Furthermore, influence of stress and stress

hormones on nociceptive processing and clinical man-

ifestation of TMD pain need to be better understood. It

will not be possible to employ rational and biologically

based treatments for TMD-related pain until these

mechanisms are defined more clearly and precisely than

they are now. This should lead to much more effective

means for treatment and possibly prevention of TMD-

related pain and dysfunction.

Orthodontics, occlusion and TMD


The current literature does not support any strong

associations between occlusal variables and TMD or any

significant beneficial or detrimental effects of ortho-

dontic interventions on manifest TMD pain (2). Twocaveats, however, need to be recognized.

First, there is lack of specificity regarding the defini-

tion of ‘occlusion’ and ‘malocclusion’. From a clinical

point of view, malocclusion could be any occlusion in

which the structural characteristics are different from

those established for a theoretically ‘ideal’ occlusion.

Although ‘ideal’ is difficult to define, a definition is

undoubtedly necessary if rational treatment goals are to

be established. It is also critical to recognize that even if

‘ideal’ has no bearing on what is ‘normal’ or ‘typical’ in

terms of what is necessary for health, reconstruction of

teeth (and supporting structures) according to ideal

standards should be a target of treatment if treatment is

indicated for other reasons, given that the boundary of

what constitutes clinically acceptable is even harder to

define. By extension, even if the prefix ‘mal’ means

‘bad’ or ‘ill’, the term ‘malocclusion’ does not neces-

sarily imply that such an occlusion is non-physiologic

or that therapy is indicated.

Second, it is important to recognize that the term

‘TMD’ has been used, and still is used, very differently

in the published literature; for example, the criteria

used to denote presence or absence of TMD vary.

Indeed, TMD is a very general term that defines a wide

group of clinical entities (5), each with quite different

and mostly unknown aetiology and pathophysiology(1) that only share in common the clinical features of

producing pain and ⁄ or functional limitation in the

masticatory apparatus. Therefore, research protocols

should continue to investigate well-defined subtypes

without merging pain, joint sounds and ⁄ or mechanical

dysfunction as though those symptoms necessarily

represent a single disorder.

Recommendations

While the current literature clearly supports the

absence of a relationship between occlusion and TMD,

definitional problems warrant further exploration of

possible associations between occlusion and TMD. This

recommendation is not made to suggest that such an

association exists, but rather it is made in the interest of

adhering to the principles of good science: methodo-

logical problems that may underlie the absence of

proposed relationships deserve further exploration.

To pursue further exploration of any possible rela-

tionship between occlusion and TMD, three develop-

ments are needed: (i) the boundary between acceptable

versus pathologic occlusion needs to be much betterdelineated; (ii) the existing occlusal variables that have

already received much attention in published research

need to be augmented by additional factors pertaining to

the occlusion; and (iii) subtypes of TMD, which may

have greater potential to be affected by structural factors,

need to be defined based on mechanisms by which the

putative structural factors would affect the subtypes and

why specific subtypes might be more at risk.

ª 2010 Blackwell Publishing Ltd

B . C A I R N S et al.482


3/9

It is notable that most research regarding occlusion

and TMD has been limited to structural characteristics

associated with purely static occlusion (e.g. Angle’s

classification) or with pre-defined aspects of articulation

(e.g. so-called balancing interferences), assuming that

there is necessarily some measurable functional corre-

late or consequence of the identified characteristic. As

more specific recommendations for further exploration,

four directions are suggested. The first involves true

dynamics of how structure and function interrelate

(e.g. mastication where a bolus of food prevents actual

tooth contact for the most part, or parafunctional

behaviours involving direct tooth–tooth contact) which

are poorly understood and clearly deserve more

research to understand the relative contributions of

structure and functional patterns to TMD onset or

maintenance.

The second direction involves symptom perceptionassociated with occlusal structures. Based on research

in other areas of chronic pain (e.g. back pain), cognitive

(e.g. catastrophizing), attentional (e.g. hypervigilance)

and perceptual (symptom amplification) factors clearly

contribute to psychophysiologic reactivity, treatment

seeking and perpetuation of the condition. Of these,

one factor in particular, hypervigilance – a state in

which an individual, possibly because of a combination

of predisposing genetic, psychosocial and environmen-

tal factors, is exceedingly aware of the sensory experi-

ence associated with a part of the body – merits

investigation in association with occlusal variables.

Hypervigilance is hypothesized to account for reported

outcomes of occlusal treatment in patients with TMD

where symptoms associated with the occlusion and, in

particular, any modifications performed on the occlu-

sion, independently of its anatomical or functional

status, are predominant. Research and better under-

standing of hypervigilance as a ‘perceptual habit’ in

which attention is focused on sensations of a particular

type with subjective amplification of perceptions will be

needed. It can be speculated that hypervigilance,

together with other psychological states such as anxietyor catastrophizing, could be a risk factor in patients with

TMD when the therapeutic management includes a

modification of the occlusion. Any alteration of the

existing occlusal pattern (even if minimally invasive)

may, especially in these patients, trigger a ‘bodily

distress disorder’ (as has been termed in the back pain

area), e.g. an occlusal dysesthesia disorder leading to

further distress.

A third direction warranting more research is the

adaptive capability or resilience of the individual which

could influence the definition of ‘normal’ as well as the

results of any typical occlusal interventions provided to

patients with dental restorative needs (or perhaps

aesthetic needs) and who also have a TMD with, we

assume, an external aetiology (e.g. trauma to the jaw).

One testable hypothesis is that TMD causes irreversible

degenerative alterations in the masticatory apparatus

and, consequently, the system reacts with adaptive

changes, in some cases also irreversible, in an attempt

to regain the functional equilibrium. In this clinical

situation, any occlusal modification procedure per-

formed in these patients, even if appropriately indicated

for occlusal rehabilitation purposes and technically

correct, may exceed the adaptation capability of the

system, the patient, or both, compromising the clinical

status of the condition. Adaptation capability is impor-tant for all of dentistry, in that procedures regarded by

the profession as routine may not be routine for a given

individual, and consequently occlusal modification

performed as part of an extensive plan of restorative

treatment may exceed that capability and trigger the

onset of an iatrogenic ‘TMD’.

A fourth direction is the relation between occlusal

characteristics and muscle activity. Hyperactivity of the

masticatory apparatus may include both functional

(chewing habitual food, chewing gum, tobacco, sun

seeds) and ‘parafunctional’ oral habits, including but

not restricted to non-functional tooth contacts; clench-

ing and grinding of the teeth; biting of objects such as

nails, fingers, or lips; and non-tooth contact behaviours

such as bracing or thrusting the jaw. Carefully designed

research projects are still needed to evaluate whether

patients with waking-state or sleep-state non-func-

tional tooth contacts are at higher risk of developing

particular subtypes of TMD; what has not been consid-

ered with this well-known question is whether the

effects of these parafunctional behaviours occur per-

haps in an occlusal-dependent manner. The current

literature does not support the belief that occlusion perse influences the occurrence of non-functional tooth

contacts; however, the interaction between occlusal

variables and specific patterns associated with para-

functional activity should be evaluated to determine

(i) the boundaries of ‘normal’ for occlusal status;

(ii) whether occlusal modifications in patients with

TMD are more risky if the patient already has or is

independently at risk for increased muscle activity


J O R - C O R E 2 0 0 9 R E C O M M E N D A T I O N S 483


4/9

related to parafunctional behaviours; and (iii) whether

otherwise non-TMD patients with increased muscle

activity (e.g. the individual with chronic asymptomatic

sleep-bruxism) are at higher risk of developing a TMD

when undergoing an occlusal modification procedure.

In conclusion, there is a need for critical thinking and

careful planning of well-designed studies before the

associations between occlusal variables and TMD are

attempted to be (re)examined.

Reviews of management of TMD pain


It is difficult for anyone to stay current with the

constant growth of new scientific information and

professional recommendations and to simultaneously

evaluate the reliability, validity and applicability ofpublished results, and it is particularly difficult for full-

time clinicians to do this (3). Dentists must find a way

to manage this expanding mass of new knowledge – a

way to filter and compile the information - so that it is

clinically useful. Evidence-based medicine (EBM) is the

integration of (i) best research evidence with (ii) clinical

experience and (iii) patient values. These three ele-

ments are essential to integrate to achieve optimal

clinical outcome and quality of life for the patient.

Clinicians and patients form a diagnostic and therapeu-

tic alliance that has the potential to optimize clinical

outcomes and quality of life.

Our aim here is to focus on how EBM needs to be

integrated in clinical practice, research settings and

undergraduate teaching and to discuss benefits and

limitations of clinical trials and systematic reviews

(SRs).

EBM in clinical and research settings Two important

elements in EBM, research evidence and clinical

expertise, are nicely defined by Sackett et al. (6):

(i) Best research evidence means clinically relevant

research emerging not only from the basic sciences butalso from patient-centred clinical research regarding the

accuracy and precision of diagnostic tests (including the

clinical examination, prognostic markers, and the effi-

cacy and safety of therapeutic, rehabilitative and

preventive regimens) and (ii) clinical expertise is the

ability to use our clinical skills and past experiences to

rapidly identify each patient’s unique health state and

diagnosis, their individual risks and benefits of potential

interventions, and their personal values and expecta-

tions.

In EBM, evaluation of a patient and subsequent

treatment decisions are a combination of (i) the

available literature and investigations, (ii) clinical

experience and (iii) the specific needs of each patient.

It would seem obvious that in clinical practice, the EBM

approach should benefit the patient. The question,

however, is whether busy clinicians are prepared to use

all three elements? How does the shortage of consistent

scientific evidence affect implementation of treatment?

How eager are clinicians to apply new knowledge and

skills in clinical practice?

One limitation to the practice of EBM is the gener-

alizability of studies [e.g. randomized clinical trials

(RCT), case–control studies] to the typical clinical

setting. Studies often have very specific inclusion and

exclusion criteria, which sometimes do not capture thetypical patient. Therefore, the generalizability from an

RCT to the patient in the clinic may be unclear. Some

instruments used extensively in research, such as the

RDC ⁄ TMD, are considered by some practitioners as

time consuming and not always practical to use in a

busy clinical practice. Standardized screening examina-

tion procedures and short-form self-report instruments

are a useful alternative approach for transferring to

clinical practice some of the core principles used in

clinical research.

SRs, because they provide the best available research

evidence for a specific issue, can be useful for clinicians

and patients. Recommendations from SRs are not

always conclusive, however, and consequently, SRs

are likely to be most useful in excluding treatment

strategies that are highly unlikely to be beneficial. This

knowledge can be used in clinical decision-making and

for educating the patient. One limitation is that clini-

cians who are not trained in EBM would have problems

advising and disseminating this information to the

patient because it requires a significant shift in how one

uses evidence and scientific logic.

EBM in undergraduate education The focus in EBM

teaching has always been a patient-centred clinical

situation. EBM emphasizes interactive, learner-centred

activities for self-directed life-long learning. In under-

graduate education, the major benefit of EBM is that

students are taught how to think critically and ask

themselves questions. One limitation is that because

not all teachers are trained in evidence-based medicine,




5/9

EBM is taught as a separate subject and not integrated

into the curricula in the dental schools.

Does EBM improve outcome for patients? In the medical

field, studies have reported that those patients who

receive evidence-based therapies have better outcomes

than those who do not. Although no RCT that focuses

on that specific issue applied to TMD has been

published, it is reasonable to assume that the findings

from such studies in other areas are applicable to TMD,

such that we can suggest that EBM does improve

patient care for TMD. Economic conditions and med-

ical insurance policies, however, may vary from

country to country and profoundly influence the

choice of treatment and its extensiveness. The treat-

ment, as identified through EBM, is not always

available to patients.

The third important element in EBM is patient valuesand it was defined by Sackett et al. (6) as the unique

preference, concerns and expectations each patient

brings to a clinical encounter and which must be

integrated into clinical decisions if they are to serve

the patient. So the individual perspective, chief com-

plaint, lifestyle, culture and expectations of each patient

must be considered in selecting a particular treatment

strategy.

Methodological concerns in clinical trials Common prob-

lems in study design in several studies include small

sample size, randomization, blinding and unreliable or

non-patient-oriented measures. The results of investi-

gations are not always generalisable because the

patient’s condition, diagnosis and treatment differ from

the features of patients and treatments normally found

in clinical practice. Most studies relate their results to

quantitative measures such as pain intensity, pain

frequency, or medicine consumption, all of which are

commonly accepted if not recommended therapeutic

end-points for clinical trials but which are not neces-

sarily the variables of greatest concern to a given

patient. Qualitative research would be an alternativeapproach. If quantitative research methods best mea-

sure the impact of TMD pain in a group, it may be

that qualitative research best describes the impact of

TMD pain in an individual. The aim of qualitative

research is to understand the phenomena in natural

rather than experimental settings, with an emphasis

on understanding the experiences and values of our

patients.

Benefits and limitations of a SR SRs are valuable because

they provide a concise and easily read overview for

both the clinician and researcher of the literature on a

specific issue, and it provides a pool of readily identified

quality studies. An SR can be used to educate and guide

patients so that they more easily understand their

condition and will adhere to treatment. However, the

value of an individual SR cannot exceed the value of

the studies being reviewed: if there are inherent

limitations in the cited RCTs (e.g. generalizability

problems), conclusions from the SR will be similarly

limited. Additionally, if conclusions are mixed, the

clinician will probably have to read the individual

studies contained in the SR because one factor deter-

mining the applicability of various research findings to

a particular patient is the match in characteristics

between the given patient and the subject pool of the

particular study. Also, more recent studies or studiesthat were inadvertently not included in the SR could

affect the recommendations.

Benefits of SRs include the time they save by focusing

on only quality studies and the possibility to exclude

therapies that lack success or are harmful.

Recommendations

Research methods which allow patient-specific tailor-

ing of treatment outcomes are needed. Such methods

would weight those outcomes that are important for a

particular patient more heavily than outcomes that

are less important for that patient. For example, if

patient #1 thought that better quality sleep was

highly important, sleep measures would have higher

weight in her outcome data than other measures that

she considered less important; if patient #2 thought

that pain-related affect was most important, this

outcome measure would be weighted more highly

than others. Such an approach might allow for

research summaries that consider whether the inter-

vention generally provided improvement in symptom

areas that were most important for patients, evenif different patients weighted different outcomes

differently.

To minimize mistakes in study design, CONSORT

recommendations should be followed by the researcher

and required by all journals that publish clinical trials.

Basic science studies should be designed in a manner

likely to make them translatable into at least clinical

research if not clinical practice. In a clinical research




6/9

setting, more evidence regarding accuracy and preci-

sion of diagnostic tests is needed. In addition, more

evidence is needed about TMD and the impact that

TMD exerts on patients’ daily lives (see also Section on

Disability).

Knowledge regarding patient preferences with re-

spect to treatments and the determinants of treatment

compliance is currently limited. A qualitative meth-

odological approach would probably shed some light

on this issue and improve patient outcome measures.

However, medical journals often will not publish

qualitative studies because of reviewers having

insufficient training and appreciation of qualitative

methods.

In a research setting, it is important that the assess-

ment of treatment outcomes include multiple domains

which together can capture a more comprehensive

picture of the pain condition. For patients with TMDwith chronic pain, IMMPACT recommendations

include these domains: pain; physical functioning;

emotional functioning; participant rating of improve-

ment and satisfaction with treatment, symptoms, and

adverse events; and participant disposition (7). These

domains are being modelled within the revision to the

RDC ⁄ TMD [see also Ohrbach et al. (8)].

Disability


Limitation and disability is a major issue in TMD, and

these concepts coupled with pathophysiology and

impairment are collectively referred to as disable-

ment (4). And, as Michelotti and Iodice (2) and Ohrbach

(4) have shown, these concepts apply to other areas of

dentistry as well. However, it seems to be a global

challenge to incorporate the concept of disablement into

dental education and dental clinical practice consistent

with published descriptions of the problem. In addition,

there is a lack of appreciation of the consequences of not

addressing disability within dentistry (9). Given themagnitude of this challenge, the most streamlined

approach for ready integration of disablement assess-

ment into everyday clinical practice requires respect for

and adherence to several key principles:

1 Clinical practice is challenging with respect to both

technical skills and clinical time management. At

present, management of patients’ biomedical expecta-

tions of dental treatment can be difficult. Transforming

the practitioners’ practice to a biopsychosocial orienta-

tion will, therefore, be even more demanding of skill

and time. The question must therefore be posed as to

how to train dentists in this skill?

2 Any attempted assessment of disablement must be

pragmatic and must transparently fit into any general

dental setting.

3 The outcome of the disablement assessment must be:

unambiguous to the general dental practitioner; prac-

tical within the context of an ongoing dental setting;

and useful to the patient and the practitioner.

A model already in use for assessing back painwhich incorporates the concept of red flags and

yellow flags (10)1 to make disablement assessment a

key part of primary medical care may have merit for

providing a framework for assessing disablement in

Initial or returning (new complaint) patient

(Captive time in a waiting room)

YesSignificant yellow flags

warrant immediate concern ?

Clinical evaluation:History – intervieaw for yellow flags

Review screener responses and scores

Patient completes screener for distress and social disability

Refer for specialist

consultation*

No

Proceed/continue treatment

Making good progress

Scheduled review (2–4 weeks)(rule-out red flags, monitor yellow flags)

Yes

* Minimal assessment protocol forlimitation and disability

To be used in further evaluation by thetreating clinician (as appropriate) orby referral for specialist consultation:

• pain • functional limitation • pain-related disability • depression • anxiety • non-specific (co-morbid) physical

symptoms • oral HR-QoL

No

Rule-out red flags

Re-evaluate 8 yellow flag areas

Can provideraddress positive flags?

Yes

Modify treatment

Red flags :investigate

or refer

No

Scheduled review (2–4 weeks)

(rule-out red flags, monitor yellow flags)

Further evaluation or refer*

Can provider

address positive flags?

No

Yes

Fig. 1. Flow chart for routine incorporation of disablement

assessment into general clinical practice and specialist referral.

1Red flags identify potentially serious conditions such as pain that

awakens the patient from sleep, drug addiction, or suicidal ideation

that have immediate mortality or morbidity. Yellow flags identify

psychosocial barriers to reasonable treatment response.




7/9

everyday clinical practice. The ‘flag’ type of system

should reduce the burden of such assessment within

dentistry, thus ensuring that all patients in a given

setting receive the same level of initial screening for

limitation and disability. The screening and resultant

presence or absence of flags would then determine

whether or not a formal minimal assessment protocol

for limitation and disability was indicated, thereby

reducing the number of formal assessments that

routine day-to-day dentistry might demand (see

Fig. 1).

Recommendations

For implementing routine assessment of disablement

status of individuals being evaluated and treated in

dental settings, a stepped approach comprised of

screening followed, as needed, by more formal assess-ment is recommended. A stepped approach is increas-

ingly regarded as the most efficient method for

collecting context-relevant information. Based on evi-

dence from other areas of medicine, the screening stage

should focus on the identification of yellow and red

flags. Clinical data pertaining to flags can be easily

obtainable in routine clinical dentistry using two

methods for screening: (i) a standardized self-report

instrument for information not readily obtained via

other methods and (ii) clinical interview (history) for

complaint-relevant information. The outcome of such

information acquisition should then denote specific

courses of action.

The self-report instrument should examine, in no

more than 20 items, distress and social disability.

Distress and social disability were selected as useful

screening constructs for disability as it was envisioned

that they would capture significant elements of disabil-

ity and handicap. A threshold, to be determined, in the

self-report instrument would indicate whether it was

necessary or appropriate (or not) to proceed with

completion of the minimal formal disability assessment

set to more accurately examine the level of disability ofthe patient in question. This is believed to be a

pragmatic approach to the problem of disability assess-

ment for the busy clinician, as not all patients will need

a full disability assessment for every complaint. The

distress portion of the instrument would also assess for

significant problems such as suicidal ideation. The

distress and social disability screening instrument needs

to be further developed.

The second method of determining flags is through

the clinical interview (history). Implicit in this method

is the need for additional educational and clinical

training so that dental practitioners are comfortable

and well versed with core psychosocial issues in a

history. Some of the ‘flag’ areas that might be associated

with history-taking and might merit further investiga-

tion are:

1 Chronicity. Determine the chronicity of the complaint;

chronic pain, for example, is associated with greater

likelihood of clinically significant depression and alter-

ations in central nervous system processing of nocicep-

tive stimuli.

2 Functional limitation. Assess functional limitation

status with regards to chewing, jaw mobility and use

of the jaw for other functions; these areas would be

explored via simple interview questions to determine

whether the individual has such problems, and theexpected form of the responses need only be binary

(yes, no) but could obviously be elaborated. For

example, pain associated with a temporomandibular

disorder should be accompanied by problems in jaw

function as a minimum.

3 Discrepancy in findings. Determine whether there is a

discrepancy between reported symptoms versus ob-

served findings; such discrepancies can point to signif-

icant other factors contributing to the individual’s

symptom report.

4 Overuse of medication. Review medication history for

prolonged or excessive use of opiates, benzodiazepines,

alcohol, or other drugs.

5 Inappropriate behavior . Observe for behaviour inap-

propriate to the complaint; such behaviour can be

explicit or implicit.

6 Inappropriate expectations. Determine whether the

patient’s expectations regarding character or outcome

of treatment are unrealistic or inappropriate; such

expectations on the part of the patient can point to a

number of underlying problems that typically interfere

with good health care delivery. Note that providers may

also have unrealistic or inappropriate expectationsabout the presumed outcome of recommended treat-

ment but that is a problem that needs attention

elsewhere.

7 Inappropriate responsiveness to (prior) treatment . Deter-

mine whether prior treatment has been associated with

inappropriate response in the patient’s symptoms; failed

prior treatments do not bode well for the currently




8/9

planned therapy. This yellow flag is also assessed by

the provider at each follow-up visit of his ⁄ her own

treatment.

8 Identify red-flags from self-report screener . Suicidal

ideation is one symptom within this portion of the

evaluation that is a red flag and requires immediate

action. Other possible red flags warrant further

investigation and will be determined, for the most

part, by the final content of the screener as well as by

evolving standards for taking a history of pain

complaints as well as by reviewing the medical

history.

The two methods for determining flags are imple-

mented into a modification of the care system for a

dental patient as shown diagrammatically in Fig. 1.

While the minimal assessment procedures for screening

via identification of yellow and red flags should

contain, as bulleted in Fig. 1, assessment of multipleareas, it remains nevertheless lean, efficacious, effi-

cient, easily integrated into procedures already per-

formed, and highly sensitive.

Implementation in clinical settings

In reference to Fig. 1, stepped minimal disability

assessment that includes administration of the stan-

dardized screening instrument, interview questions,

interpretation of psychosocial yellow flags (and

biomedical red flags) and appropriate review at

subsequent office visits would proceed as follows. A

new patient, or a returning patient with a new

complaint, completes the self-report distress and social

disability screener and it is scored prior to the

dentist’s exploration of the presenting complaint.

The history-based yellow flags are explored during

the history of complaint. These and any further

positive flags are noted in the patient’s record. The

number of yellow flags needed to trigger the use of

the formal minimal disability protocol is not yet

established, but clearly descriptive information asso-

ciated with any positive yellow flags should enter intoclinical decision-making and possibly lead to stepped

progression of the evaluation. Moreover, it would

seem intuitive that any red flag should result in

immediate attention for further investigation and or

referral.

At the first return visit progress via either symptom

status or other measures could be assessed, and if the

patient is flagged as having an inappropriate response to

the treatment provided, then the provider should

reconsider the diagnosis, treatment, or both. If inap-

propriate response to treatment is flagged at this visit,

the provider would also revisit all yellow flag screening

items as well as exclude red flags. One more cycle of

treatment could then be considered. If treatment now

progresses well, the provider should continue with

treatment and continue to monitor for red and yellow

flags.

If the second cycle of treatment does not proceed

well, further diagnostic evaluation in the area of

disablement is indicated; certainly other medical

evaluation should be considered at this stage as well

in that poor progress with treatment could be because

of either medical or psychosocial factors, and each

should be further investigated at this stage without

neglecting the other. This further investigation of

psychosocial factors would be performed throughapplication of the minimal assessment protocol for

limitation and disability. The initial provider can

pursue this assessment, if prior training and experi-

ence provide the necessary clinical skills, or the

provider could refer the patient at this juncture to a

specialist who has that training. These constructs

would then be assessed by the specialist at the

beginning of evaluation in lieu of using the distress

and social disability screener.

These recommendations, however, form a new per-

spective that requires testing to obtain evidence for its

validity and utility. Therefore, these recommendations

entail: (i) instruments and instrument sets must be

developed and thoroughly tested and (ii) extensive field

testing of the practicality of the proposed protocol for

assessing disability in dentistry must take place. This

work is critical to ensure that any large scale changes

made in the practice of clinical dentistry are evidence

based and robust.

Conclusions

The present summaries and recommendations are based on the extensive reviews (1–4) and discussion

within the four working groups during the JOR-

CORE. Overall, these recommendations are based on

current understanding of the published dental litera-

ture, particularly as it relates to TMD pain, and

provide a framework to move rehabilitation of not

only patients with TMD but all dental patients

forward.




9/9

Acknowledgments

The sponsors Wiley-Blackwell and Medotech Aps are

thanked for their financial support to the JOR-CORE

which would not have been possible without the

financial aid.

The authors, who are listed in alphabetical order,

extend appreciation to the workgroup members for

their valuable input and contributions to previous

versions of this recommendation. The workgroup

members were:

Pathophysiology workgroup members

Iva Alajbeg (Croatia), Altair Del Bel Cury (Brazil), Sibel

Dincer (USA), Malin Ernberg (Sweden), Gary Heir

(USA), Adriaan Klitsie (Netherlands), Howard

Tenenbaum (Canada).

Occlusion and orthodontic workgroup members

Taro Arima (Japan), Jose Luis de la Hoz (Spain),

Susanne Elmasry Ivanovic (Sweden), Malvin Janal

(USA), Pinar Kursoglu (Turkey), Tomohiro Tanosoto

(Japan), Ephraim Winocur (Israel), Luo Xiaoping

(China).

Systematic review workgroup members

Jari Ahlberg (Fin), Maria Clotilde Carra (Italy),

Fernanda Foat (Brazil), Nikolaos Giannakopoulos

(Germany), Ebru Ispirgil (Turkey), Karen Raphael

(USA), Claudia Restrepo (Columbia), Olcay Sakar

(Turkey).

Disability workgroup members

Justin Durham (UK), Anat Gavish (Israel), Jordi

Martinez-Gomis (Spain), Yoshihiro Tsukiyama (Japan),

Wataru Yachida (Japan).

References

1. Cairns BE. Pathophysiology of TMD pain - basic mechanisms

and their implications for pharmacotherapy. J Oral Rehabil.

2010;37:391–410.

2. Michelotti A, Iodice G. The role of orthodontics in tempor-

omandibular disorders. J Oral Rehabil. 2010;37:411–429.

3. List T, Axelsson S. Management of TMD: Evidence from

systematic reviews and meta-analyses. J Oral Rehabil. 2010;

37:430–451.

4. Ohrbach R. Disability assessment in temporomandibular dis-

orders and masticatory system rehabilitation. J Oral Rehabil.

2010;37:452–480.

5. Dworkin SF, LeResche L. Research diagnostic criteria for

temporomandibular disorders: review, criteria, examinations

and specifications, critique. J Craniomandib Disord Facial Oral

Pain. 1992;6:301–355.

6. Sackett D, Straus S, Ws R, Rosenberg W, Haynes R. Evidence-

based medicine. How to practice and teach EBM. Edinburgh:

Churchill Livingstone, 2000.

7. Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, JensenMP, Katz NP, et al. Core outcome measures for chronic pain

clinical trials: IMMPACT recommendations. Pain. 2005;113:

9–19.

8. Ohrbach R, List T, Goulet J-P, Svensson P. Recommendations

from the International Consensus Workshop: Convergence on

an Orofacial Pain Taxonomy. J Oral Rehabil. 2010; In press.

9. Locker D. Measuring oral health: a conceptual framework.

Community Dental Health. 1987;5:3–18.

10. New Zealand Guidelines Group. New Zealand Low Back Pain

Guide. 2004. Wellington, New Zealand.

Correspondence: Svensson P, Department of Clinical Oral Physiology,

School of Dentistry, Aarhus University, 8000 Aarhus C, Denmark.

Email: [email protected]



CAIRNS Et Al-2010-Journal of Oral Rehabilitation

Documents

Transcript of CAIRNS Et Al-2010-Journal of Oral Rehabilitation