2000-12-1-2-9-full - Saudi Dental Journal

ISSN (Print) 1013-9052
EISSN 1658-3558

The Saudi Dental Journal,
P.O. Box 52500,
Riyadh 11563,
Kingdom of Saudi Arabia

Tel.	966-1-467-7328
Fax.	933-1-467-7308 / 966-1-467-7534
Email	saudidj@ksu.edu.sa

History for temporomandibular disorders - A simplified technique

N. Joseph Nassif, DDS, MSc, FACP

Associate Professor, Department of Prosthetic Dental Sciences College of Dentistry, King Saud University P.O. Box 60169, Riyadh 11545, KSA

Abstract

As a result of the widespread nature of temporomandibular disorders (TMD), a screening for its occurrence has been recommended as a part of the routine dental examination by leading dental organizations. The purpose of this study was to provide dentists and other health care providers with an Arabic i Ml) routine history form, after being modified and translated from a recent English one and evaluated clinically. One hundred Saudi male subjects were used to trial test the Arabic TMD routine history form. The median time for patients to fill the form was 2 minutes. Immediately after completing the TMD form, each subject was given a survey questionnaire form to fill out, in order to determine if the routine history form was "clear and understandable." The survey findings indicated that 77 per cent of the subjects understood all 16 items on the Arabic routine history form. The remaining 23 per cent of the subjects had some difficulty in understanding one (or both) of two items, related to not knowing the meanings of 'temple area' and 'teeth clenching and grinding.' Recommendations were made in order to add clarity to the two "unclear items" for dental patients. Further, reasons for needing the Arabic TMD routine history form (along with a TMD screening examination) as an essential part of the routine dental examination are discussed.

Introduction

Temporomandibular disorders (TMD) have been defined as "a collective term embracing a number of clinical problems that involve the masticatory musculature, temporomandibular joint (TMJ), and associated structures, or both."¹ The prevalence of TMD in non-patient populations around the world has been found to be in the range of 75 percent for having at least one sign of TMD and 33 per cent for having at least one symptom of TMD.¹ Because of the widespread nature of TMD and the need for establishing more uniform principles in examination, diagnosis and treatment, the American Dental Association convened a TMD conference in 1982² and a TMD workshop in 1989.³ A significant conclusion by these conferees and by others¹'⁴-⁵ was to recommend that a TMD screening history and examination be included as an integral part of the routine dental examination. One problem encountered with TMD screening forms was to have a form that was simple to use by the patient and be easy for a dentist to interpret the findings. One such form, introduced under the auspices of the American College of Prosthodontists⁶ has been recommended by others⁴-⁵ to be used for TMD screening. The purpose of this study was to provide dentists and other health care providers with a TMD routine history form, in an Arabic version, after being modified, trial tested and translated from a recent English language history form.

Materials and Methods

A TMD routine history form, developed by the American College of Prosthodontists,⁶ was modified (Fig. 1) to accommodate usage for dental patients in the Arabic language. This modified English form, which had 16 separate entries in a check-the-box format (Fig. 1), was then translated and formatted into Arabic (Fig. 2). An accompanying survey questionnaire form in Arabic (Fig. 3), consisting of five questions, was initially formulated in the English language (Fig. 4). The Arabic survey form (Fig. 3) was given to each subject to complete immediately after he had completed the Arabic TMD routine history form (Fig. 2).
One hundred consecutive male Saudi patients, who were being treated at King Saud University College of Dentistry, Department of Prosthetic Dental Sciences, were given the Arabic TMD routine history form (Fig. 2) to complete in writing. The age range was 19 to 87 years, with the median age being 36 years. Immediately after completing the Arabic TMD history form, each subject was given the accompanying Arabic survey questionnaire (Fig. 3) to complete in writing. The time in minutes to complete the routine history form was recorded by the examiner.

Results

The amount of time for subjects to complete the check-the-box TMD routine history form ranged from one to 10 minutes, with the median time being two minutes. Seventy-five percent of the subjects completed the routine history form within three minutes. The following results were derived from the subjects' written responses to the accompanying five question Arabic survey questionnaire:
Survey Question No. 1: Are all the questions clear and understandable?
Seventy-seven (77%) subjects answered 'Yes' and 23 (23%) answered'No.' Nineteen of the 23 subjects who answered 'No' were below the median age of 36.
Survey Question No. 2: Which question number(s) was not clear or understandable?
Fourteen subjects (14%) responded that question No. 8 was not understandable (Temple pain'), and ten subjects (10%) indicated question No. 14 was not understandable ("Do you clench or grind your teeth?") (Table 1). Survey Question No. 3: Please write your comment about the question(s) which was not clear or understandable.
Thirteen subjects made short written comments. Eleven of the 13 subjects were below the median age 36. Nine subjects wrote comments on question No. 8 and five subjects on question No. 14 (includes one subject who had written comments concerning both questions). Concerning question No. 8, all of the written comments asked either, "What is 'temple?" or "Where is 'temple located?'" Concerning written comments for question No. 14, all five subjects stated, "I do not understand the words, clench or grind."
Survey Question No. 4: Do you believe that you have a temporomandibular disorder?

Yes___
No____.
Seven (7%) of the subjects answered "Yes." Only two of the subjects who answered "Yes" were among the 13 subjects who had made written comments in response to the aforementioned Survey Question No. 3.
Survey Question No. 5: Which new question do you suggest to be added to this screening form?
Four of the 100 subjects each suggested a different new question be added to the TMD screening form. The four suggested new questions were:

(a) "Is there pain when you move your jaw to the right or left?"
(b) "Do you have jaw muscle pain?"
(c) "Do you have teeth pain?"
(d) "Are your teeth healthy?"
One additional subject, rather than suggesting a new question, asked a question, "Why do you need to know about headaches?" The ages of the five subjects responding to question No. 5 were 19,19, 20, 38, and 55.

Discussion

The Arabic version (Fig. 2) of the modified English TMD screening history form (Fig.1), trial tested in this study, was well understood by 77% of the subjects. Only 23% (23 subjects) had problems in understanding one or more of the screening entries. The overwhelming majority of these 23 subjects had problems understanding either question No. 8 (temple pain) or question No. 14 ("Do you clench or grind your teeth?"). Furthermore, written comments made by 13 subjects (survey question No. 3) substantiated that they did not understand either the meaning of 'temple area,' or the meaning of "grinding or clenching" of the teeth. To make question No. 8 (temple area) more understandable on the screening form, it was decided to revise the history form and insert a "line drawing" adjacent to screening question No. 8, clearly depicting the 'temple area' (Fig. 5). A written solution was not found for further clarifying question No. 14 ("Do you clench or grind your teeth") on the screening form. Therefore, it is recommended that the health care provider demonstrate to the patient "what clenching and grinding are," before he/she completes the screening history form.

To test the understanding of the two screening corrections, twenty additional subjects were given the revised screening history form to complete (Fig. 5), along with the previously used survey questionnaire form (Fig. 3). At the same time, it was explained to each subject what was meant by 'clenching or grinding' in screening question No. 14. Afterwards, none of the twenty subjects indicated that they had a problem with the clarity and understanding any of the screening questions.
Seven of the subjects (7%) answered "Yes" to survey question No. 4 ("Do you believe that you have a temporomandibular disorder?"). Significantly, this survey finding compares favorably with the findings of Schiffman et al⁷ and others.⁸⁹ The former reported in a general population study that although 33% had a TMJ disorder and 41% had a masticatory muscle disorder, only 7% of the subjects had a significant clinical disorder.
It should be mentioned that this present study consisted solely in the testing of an Arabic TMD routine history form. In order to confirm positive history findings, an accompanying TMD screening examination should be performed.¹"⁶
Four subjects suggested that the following new questions (one question per subject) be added to the screening history form (survey question No. 5):
(1) Is there pain when you move your jaw to the right or left?
(2) Do you have jaw muscle pain?
(3) Do you have teeth pain?
(4) Are your teeth healthy?
Suggested new question "number one" is not necessary, since a TMD screening examination would include jaw movements for determining limitation and/or pain. Suggested question "number two" is already included in the screening history form (item No. 5). Additionally, a TMD screening examination includes palpation of the superficial/deep masseter and the temporalis muscles to determine if there is jaw muscle pain. The third and fourth suggested new questions should be a part of the routine dental examination. However, it should be mentioned that patients with moderate or severe TMD symptoms and signs, should undergo a TMD comprehensive history and examination. This would include an evaluation for the possibility of referred pain to the teeth from the temporalis, masseter and/or digastric muscles.¹⁰

Conclusions

The Arabic version of an easy-to-use TMD routune history form (original in English), was trial tested and 77 percent of the male subjects indicated that they understood all of the 16 screening items. Recommendations were made in order to clarify two items not clearly understood by the remaining 23 per cent of subjects.
A TMD routine history and examination for dental patients is recommended to be included as an essential part of the routine dental examination for the following reasons:

To establish a baseline of TMD symptoms and signs for all dental patients, so that they can be monitored during recall visits, if treatment is not indicated.¹"⁶
To disclose those dental patients with moderate or severe temporomandibular disorder conditions. Treatment or referral for the TMD condition can then be instituted.¹⁶
As a pre-treatment indicator of existing TMD conditions before initiating major dental procedures, and/or long term dental care, including fixed prosthodontics, implant dentistry,periodontal surgery, oral surgery procedures, and orthodontics.¹⁶4. As a medico-legal document to attest that the health care provider has rendered state-of-the-art care in screening his patients for TMD.⁶Another TMD screening research study, on female Arabic subjects, is currently underway in order to assess as to whether the aforementioned TMD routine history items are clear and understandable.

Acknowledgement

The author gratefully acknowledges the assistance of Drs. Yousef F. Talic, Mohammad Al Harbi, Yousef Al Ghofiliy, Khalid Al Ghamdi and senior dental student, Abdullah M. Idrees.

References

McNeill C. ed. Temporomandibular disorders.-Guidelines for classification, assessment and management. 2nd ed. Chicago: Quintessence, 1993.
Griffiths RH. Report of the president's conference on examination, diagnosis and management of temporomandibular disorders. J Am Dent Assoc 1983;106:75-7.
McNeill C, Mohl ND, Rugh JD and Tanaka T. Temporomandibular disorders diagnosis, management, education and research. J Am Dent Assoc 1990;120:253-263.
Carlsson GE, Johansson A and Wedel A. The role of general practitioners in diagnosis and management of TMD. Part I: Background and diagnosis. Postgrad Dent Middle East 1995;5:26-32.
Okeson JP. ed. Orofacial pain: Guidelines for assessment, diagnosis and management. American Academy of Orofacial Pain. Chicago: Quintessence, 1996.
Nassif NJ and Hilsen KL Screening for temporomandibular disorders: History and clinical examination. J Prosthodont 1992,1:42-6.
Schiffman E, Fricton J, Haley D and Shapiro BL. The prevalence and treatment needs of subjects with tempromandibular disorders. J Am Dent Assoc 1989;120:295-304.
Rugh JD and Solberg WK. Oral health status in the United States: Temporomandibular disorders. J Dent Educ 1985;49:398-404.
Dworkin SF, LeResche LR, Von Korff C, Howard J, Truelove E and Sommers E. Epidemiology of signs and symptoms in temporomandibular disorders: I. Clinical signs in cases and controls. J Am Dent ASSOC 1990;120:273-81.
Okeson JP. Management of temporomandibular disorders and occlusion. 4th ed. St. Louis: Mosby 1998;234-309

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