2004-09-08

EACD meeting in Malmö 2004

EACD meeting in EACD meeting in Malmö 2004Malmö 2004

Classification and diagnoses in Classification and diagnoses in temporomandibular disorders temporomandibular disorders

(TMDs)(TMDs)

SigvardSigvard Kopp DDS, PhDKopp DDS, PhDKarolinska InstitutetKarolinska Institutet

2004-09-08

DiagnostiDiagnosticccategorization should categorization should be based on be based on etiologyetiologyand and pathophysiologicpathophysiologic

mechanismsmechanisms

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DiagnostiDiagnosticccategorization is mostly categorization is mostly

based on symptoms based on symptoms and signs (clinical and and signs (clinical and

radiographic)radiographic)

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Diagnostic classification Diagnostic classification systems for TMDsystems for TMD

American Academy of Orofacial Pain American Academy of Orofacial Pain (AAOP) (AAOP) -- ICHD 1994 ICHD 1994 –– McNeill 1990,1993, McNeill 1990,1993, Okeson 1996Okeson 1996

Research Diagnostic Criteria (RDC) 1992Research Diagnostic Criteria (RDC) 1992Dworkin & LeResche 1992 Dworkin & LeResche 1992

Other common system (ICDOther common system (ICD--10, IASP)10, IASP)Future possibilitiesFuture possibilities

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Diagnoses based onDiagnoses based on

Etiology ?Etiology ?Pathophysiology ?Pathophysiology ?Signs and symptoms ?Signs and symptoms ?Pain characteristics ?Pain characteristics ?Behavioral characteristics ?Behavioral characteristics ?

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AAOPAAOP--IHS:IHS:TemporomandibularTemporomandibular DisordersDisorders

((TMD)TMD)

11.7:11.7: TemporomandibularTemporomandibularjoint joint articulararticular disordersdisorders

1111.8:.8: Masticatory muscle Masticatory muscle disordersdisorders

(Okeson 1996)

To be used by the clinician?

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TemporomandibularJoint TemporomandibularJoint disorders disorders

11.7.1:11.7.1: Congenital or developmental disorders Congenital or developmental disorders

1111.7.2: .7.2: DiscDisc derangement disorders derangement disorders

11.7.3: 11.7.3: TMJTMJ dislocationdislocation

11.7.4:11.7.4: Inflammatory disordersInflammatory disorders

11.7.5:11.7.5: Osteoarthritis Osteoarthritis (non(non--inflammatory disorders!)inflammatory disorders!)

11.7.6: 11.7.6: AnkylosisAnkylosis

11.7.7:11.7.7: FractureFracture ((condylar condylar process)process)

(Okeson 1996)

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Inflammatory Disorders Inflammatory Disorders (11.7.4) (11.7.4) ICD.9.CM 727.09ICD.9.CM 727.09

11.7.4.111.7.4.1 Synovitis and capsulitisSynovitis and capsulitis((monoarthritismonoarthritis which can be which can be immunologic, septic or traumatic)immunologic, septic or traumatic)

11.7.4.211.7.4.2 Polyarthritides Polyarthritides (ICD.9.CM 714.9 (ICD.9.CM 714.9 unspecified) unspecified)

(Okeson 1996)

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Synovitis and capsulitisSynovitis and capsulitis((11.7.4.1) 11.7.4.1)

Mandatory diagnostic criteria:Mandatory diagnostic criteria:1. Localized TMJ pain exacerbated by 1. Localized TMJ pain exacerbated by

function, especially with superior or function, especially with superior or posterior loading and palpationposterior loading and palpation

2. No extensive osteoarthritic changes2. No extensive osteoarthritic changes

with hard tissue imaging with hard tissue imaging ??

(Okeson 1996)

2004-09-08

Synovitis and capsulitisSynovitis and capsulitis((11.7.4.1) 11.7.4.1)

Additional diagnostic criteria:Additional diagnostic criteria:Localized TMJ pain at restLocalized TMJ pain at restLimited range of motion secondary to painLimited range of motion secondary to painFluctuating swelling (due to effusion) that Fluctuating swelling (due to effusion) that decreases ability to occlude on ipsilateral posterior decreases ability to occlude on ipsilateral posterior teethteethA bright MRI signal when fluid is present (T2 A bright MRI signal when fluid is present (T2 weighting)weighting)Ear painEar pain

(Okeson 1996)

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SynovitisSynovitis--CapsulitisCapsulitis ??Anatomic backgroundAnatomic background

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Polyarthritides Polyarthritides (11.7.4.2) (11.7.4.2) ICD.9.CM 714.9 unspecifiedICD.9.CM 714.9 unspecified

Mandatory diagnostic criteria:Mandatory diagnostic criteria:

Pain with mandibular functionPain with mandibular function

Point tenderness on TMJ palpationPoint tenderness on TMJ palpation

Limited range of motion secondary to pain Limited range of motion secondary to pain ??

Radiographic evidence of extensive TMJ Radiographic evidence of extensive TMJ changes changes (Why? Erosions?)(Why? Erosions?)

(Okeson 1996)

+ multiple other joint involvement !multiple other joint involvement !

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Polyarthritides Polyarthritides (11.7.4.2) (11.7.4.2) ICD.9.CM 714.9 unspecifiedICD.9.CM 714.9 unspecified

Additional diagnostic criteria:Additional diagnostic criteria:

Any of the characteristics of OA Any of the characteristics of OA (?)(?)Pain while the mandible is at restPain while the mandible is at restBilateral TMJ and Bilateral TMJ and multiple other joint multiple other joint involvementinvolvementPositive laboratory serology testPositive laboratory serology testCrepitus with condylar translationCrepitus with condylar translation

(Okeson 1996)

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PolyarthritidesPolyarthritides

Rheumatoid arthritisPsoriatic arthritisAnkylosing spondylitisJuvenile chronic arthritisSjögren´s syndromeSystemic lupus erythematosusReiter´s syndromeCrystal-induced arthritis

2004-09-08

Reumatoid artrit ICD: 714.08A. Allmänna diagnostiska kriterier för RA enligt reviderade

ARA-kriterier 1987:1. Morgonstelhet minst 1 timme (> 6 veckor).2. Svullnad av tre eller flera leder (> 6 veckor).3. Svullnad av handled, metakarpofalangealled eller proximal

interfalangealled (> 3 veckor).4. Symmetrisk svullnad.5. Röntgenologiska förändringar i handskelett.6. Subkutana noduli.7. Positiv reumatoidfaktor.

Förekomst av fyra av de sju kriterierna säkerställer diagnos (sensitivitet 93% och specificitet 90%).

Reumatoid artrit ICD: 714.08A.A. Allmänna diagnostiska kriterier för RA enligt reviderade Allmänna diagnostiska kriterier för RA enligt reviderade

ARAARA--kriterier 1987:kriterier 1987:1. Morgonstelhet minst 1 timme (> 6 veckor).1. Morgonstelhet minst 1 timme (> 6 veckor).2. Svullnad av tre eller flera leder (> 6 veckor).2. Svullnad av tre eller flera leder (> 6 veckor).3. Svullnad av handled, metakarpofalangealled eller proximal 3. Svullnad av handled, metakarpofalangealled eller proximal

interfalangealled (> 3 veckor).interfalangealled (> 3 veckor).4. Symmetrisk svullnad.4. Symmetrisk svullnad.5. Röntgenologiska förändringar i handskelett.5. Röntgenologiska förändringar i handskelett.6. Subkutana noduli.6. Subkutana noduli.7. Positiv reumatoidfaktor.7. Positiv reumatoidfaktor.

Förekomst av fyra av de sju kriterierna säkerställer diagnoFörekomst av fyra av de sju kriterierna säkerställer diagnos (sensitivitet s (sensitivitet 93% och specificitet 90%).93% och specificitet 90%).

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Reumatoid artrit ICD: 714.08

B. Diagnostiska kriterier för käkleden:

1. Bilateralt engagemang.2. Ömhet vid lateral och posterior palpation av käkleden.3. Krepitationer i käkleden.4. Röntgenologiska erosioner i käkleden.5. Svullnad över käkleden (akut fas).6. Temperaturökning (akut fas) eller temperatursänkning

(kronisk fas) över käkleden.7. Frontal bettöppning.8. Riklig närvaro av mononukleära leukocyter (lymfocyter

och plasmaceller) i ledvätskan.

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Comments of AAOP/TMJComments of AAOP/TMJ

PositiveDiagnostic criteriaDiversified list of diagnoses

NegativeSeparate arthritides are missingCapsulitis versus synovitisOsteoarthritis – non-inflammatory!AAOP recommends use of ICD-9 for insurence matters

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Masticatory Muscle DisordersMasticatory Muscle DisordersMasticatory Muscle Disorders

11.8.1: Myofascial pain 11.8.1: Myofascial pain (ICD.9.CM 729.1) (ICD.9.CM 729.1) trigger pointstrigger points

11.8.2: Myositis 11.8.2: Myositis (ICD.9.CM 728.81) (ICD.9.CM 728.81) trauma or infectiontrauma or infection

11.8.3: Myospasm 11.8.3: Myospasm (ICD.9.CM 728.85) (ICD.9.CM 728.85) dystonia? EMG!dystonia? EMG!

11.8.4: Local myalgia 11.8.4: Local myalgia -- unclassified unclassified bruxism!bruxism!

11.8.5: Myofibrotic contracture 11.8.5: Myofibrotic contracture (ICD.9.CM 728.9)(ICD.9.CM 728.9)

XX--ray, infection, trauma ray, infection, trauma –– chronic trismuschronic trismus

11.8.6: Neoplasia 11.8.6: Neoplasia (ICD.9.CM 171.0) (ICD.9.CM 171.0)

(Okeson 1996)

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Comments AAOP/MusclesComments AAOP/Muscles

Change: LocalChange: Local myalgia myalgia ((myofascial myofascial pain pain ++local (hyperfunction) local (hyperfunction) myalgia)myalgia)

Add: Local involvement of generalised Add: Local involvement of generalised muscle pain muscle pain (e.g. (e.g. fibromyalgiafibromyalgia))

FM LM C

S1

corr

0

2

4

Ernberg et al. 1999

5-HT

2004-09-08

Two main types of muscle Two main types of muscle pain in the pain in the craniomandibularcraniomandibular

system:system:

Local involvement of Local involvement of generalised muscle pain generalised muscle pain ((fibromyalgiafibromyalgia))Local Local myalgiamyalgia ((hyperfunctionhyperfunctionmyalgiamyalgia))

SK-95 E-34

2004-09-08

RDC/TMDRDC/TMD: A set of operationalized A set of operationalized researchresearch diagnostic criteria diagnostic criteria

Axis IAxis IMuscle disordersMuscle disordersDisc Disc displacementsdisplacementsArthralgiaArthralgia, , arthritis, arthritis, arthrosisarthrosis

Axis IIAxis IIDysfunctional chronic Dysfunctional chronic painpainDepressionDepressionNonNon--specific physical specific physical symptomssymptomsJaw disabilityJaw disability

(Dworkin & LeResche 1992)(Dworkin & LeResche 1992)

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RDC axis I RDC axis I Group III:Group III: Arthralgia, Arthritis, Arthralgia, Arthritis,

ArthrosisArthrosis

ArthralgiaArthralgiaOsteoarthritis of the TMJ Osteoarthritis of the TMJ ((inflammationinflammation))Osteoarthrosis of the TMJ Osteoarthrosis of the TMJ ((degenerationdegeneration))

(Dworkin & LeResche 1992)

2004-09-08

RDC axis IRDC axis IGroup III:Group III: Arthralgia: Arthralgia: criteriacriteria

Pain in one or both joints during Pain in one or both joints during palpation andpalpation andPain in the joint at rest or Pain in the joint at rest or movement movement Crepitus absent Crepitus absent ??

(Dworkin & LeResche 1992)

2004-09-08

TMJ inflammation or not?TMJ inflammation or not?The validity, sensitivity and specificity ofThe validity, sensitivity and specificity ofdigital palpation (external pressure) overdigital palpation (external pressure) overthe TMJ have to be tested toward signs the TMJ have to be tested toward signs of active inflammation within the joint of active inflammation within the joint assessed with synovial fluid analysis, assessed with synovial fluid analysis, synovial biopsies or arthroscopy.synovial biopsies or arthroscopy.

Pain in the TMJ upon mandibular Pain in the TMJ upon mandibular movement show the strongest movement show the strongest correlation to signs of inflammation correlation to signs of inflammation in the synovial fluid.in the synovial fluid.

painful TMJ movements

No One Two or moreSF-

5-H

T (

nm

ol/

L)

0

20

40

60

80

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RDC axis IRDC axis IGroup III: Osteoarthritis: Group III: Osteoarthritis: criteriacriteria

Arthralgia (above) andArthralgia (above) and

Either of: coarse crepitus or Either of: coarse crepitus or tomograms showing erosion, tomograms showing erosion, sclerosis, flattening or osteophyte sclerosis, flattening or osteophyte formationformation

(Dworkin & LeResche 1992)

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RDC axis I RDC axis I Group III: osteoarthrosis: Group III: osteoarthrosis: criteriacriteria

Absence of arthralgia, i.e. of joint Absence of arthralgia, i.e. of joint pain andpain and

Either of: coarse crepitus or Either of: coarse crepitus or tomograms showing erosion, tomograms showing erosion, scerosis, flattening or osteophyte scerosis, flattening or osteophyte formationformation

(Dworkin & LeResche 1992)

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Comments of RDC/TMJComments of RDC/TMJ

PositivePositiveReliability Reliability consideredconsideredPsychosocial Psychosocial status includedstatus includedDiagnostic criteriaDiagnostic criteria

NegativeNegativeGeneral General joint/muscle joint/muscle conditions are conditions are lacking. Axis (III)lacking. Axis (III)??Traumatic and Traumatic and septic arthritis are septic arthritis are missingmissingArthralgia Arthralgia ????

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What about neuralgias, headaches, tinnitus, sinusitis, obstructive

sleep disorders etc ????

ICD-10?

What about neuralgias, What about neuralgias, headaches, tinnitus, headaches, tinnitus, sinusitis, obstructive sinusitis, obstructive

sleep disorders etc ????sleep disorders etc ????

ICDICD--10?10?

Which system is best ?Which system is best ?None of the systems is idealNone of the systems is ideal

AAOP system best for clinical useAAOP system best for clinical use??

RDC system best for epidemiology RDC system best for epidemiology ??

ICDICD--9/10 best for statistics and 9/10 best for statistics and communication with medical authoritiescommunication with medical authorities

??

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Future possibilitiesFuture possibilities

Identification of pain and Identification of pain and inflammatory mediators in the joint inflammatory mediators in the joint (synovial fluid) or blood (synovial fluid) or blood –– Individual Individual Pain/ Inflammatory ProfilePain/ Inflammatory Profile

Pharmacological testing (pain Pharmacological testing (pain profile) with specific antagonists profile) with specific antagonists towardstowards e.g. cytokinese.g. cytokines (Remicade(Remicade®®)), 5, 5--HT HT (Kytril(Kytril®®)), PGE, PGE2 2 (NSAID), LTB(NSAID), LTB44 (glucocorticosteroid)(glucocorticosteroid)

2004-09-08

What about diagnosis What about diagnosis prognosis and progression??prognosis and progression??

Grade 01993: P1993: P--IL1IL1ββ = 8.2 pg/mL= 8.2 pg/mL 1998: P1998: P--IL1IL1ββ = 0.0 pg/mL= 0.0 pg/mL

1994:1994: PP--IL1IL1ββ = 8.1 pg/mL= 8.1 pg/mL

PROGRESSION PROGRESSION