The CMI appears to be valid for use in clinical studies, but users must be aware of its numerous ... more The CMI appears to be valid for use in clinical studies, but users must be aware of its numerous potential errors and its associated strict methodologic guidelines to ensure accuracy and reproducibility of results. The subjective nature of some items demands that the same rater who is unaware of the management status of the patient perform both evaluations. If multiple raters are used, it is recommended that the raters discuss all items, and compare scoring of demonstration subjects before the study and use a pressure algometer for muscle palpation.
The Craniomandibular Index (CMI) was developed to provide a standardized measure of severity of p... more The Craniomandibular Index (CMI) was developed to provide a standardized measure of severity of problems in mandibular movement, TMJ noise, and muscle and joint tenderness for use in epidemiological and clinical outcome studies. The instrument was designed to have clearly defined objective criteria, simple clinical methods, and ease in scoring; it is divided into the Dysfunction Index and the Palpation Index. Inter-rater reliability (three raters) and intra-rater reliability (19 patients examined twice by one rater) were tested to determine whether the instrument has operational definitions sufficiently precise to allow for consistency in use between different raters and with one rater over time. Intraclass Correlation Coefficient for inter-rater reliability was 0.84 for the Dysfunction Index, 0.87 for the Palpation Index, and 0.95 for the CMI. Correlation for intra-rater reliability was 0.92 for the Dysfunction Index, 0.86 for the Palpation Index, and 0.96 for the CMI. These results support the reliability of the CMI for use in epidemiological and clinical studies. Users are cautioned about the subjectivity of numerous items within the CMI and the strict methodological guidelines that must be followed in order to assure accuracy and reproducibility of results.
Abstract Epidemiological investigations about the prevalence of TMJ ID and osteoarthritis have la... more Abstract Epidemiological investigations about the prevalence of TMJ ID and osteoarthritis have largely reported the symptoms and signs associated with these disorders without specific criteria to establish the diagnosis. In this study, specific diagnostic criteria have been developed, using historical, clinical and tomographic items that are predictive of the presence and stage of TMJ internal derangement. The diagnostic criteria were compared to arthrotomography to assess their diagnostic accuracy. Overall, the percent agreement was 75%. The predictability of specific stages of TMJ ID varied. Overall, sensitivity and specificity of the criteria were acceptable. The diagnosis of osteoarthritis was predicted only with tomography. Utilization of these diagnostic criteria in epidemiological studies is valid due to their high overall predictiveness when applied to a large population
Masticatory myofascial pain is a relatively frequent occurrence in patientsseen by the orthodonti... more Masticatory myofascial pain is a relatively frequent occurrence in patientsseen by the orthodontist. Thus it is important to understand the management of this condition. Treatment is generally directed toward the restoration of a more physiological state in the muscles of mastication and involves medications, appliances, various forms of behavioral modification, as well as the use of muscle exercises and trigger point therapy. This article focuses on the role of the latter modalities in the management of myofascial pain and dysfunction.
The efficacy of two hypnotic induction techniques on twenty subjects whose degree of hypnotic sus... more The efficacy of two hypnotic induction techniques on twenty subjects whose degree of hypnotic susceptibility had been previously determined as either high or low was compared. The two induction techniques, direct and indirect, reflected a difference in permissiveness of language, use of imagery and symbolic language, the use of the subject's experience and the perceived control by the subject. Pain threshold measures, induced by electrical tooth pulp stimulation, were assessed before, during, and after induction of hypnotic analgesia. Analysis of the data showed that the indirect technique was significantly more effective than the direct technique in changing pain thresholds regardless of susceptibility. The direct technique was significantly effective with only those subjects who received high susceptibility scores. Although interpretation of results is limited due to small sample size, the findings suggest that patients with low hypnotic susceptibility, as measured by conventional tests, may still be able to achieve useful hypnotic analgesia.
Atypical facial pain is a persistent pain in the face or intraoral region that does not fit into ... more Atypical facial pain is a persistent pain in the face or intraoral region that does not fit into the diagnostic criteria associated with specific orofacial pain disorders. This article presents the results of a study, which showed that in most cases of presumed atypical facial pain, there is a specific physical diagnosis or multiple diagnoses that causes the persistent pain. These difficult to diagnose disorders are reviewed with discussion of future research that is needed in this area.
Although most cases of temporomandibular muscle and joint disorders (TMJD) are mild and self-limi... more Although most cases of temporomandibular muscle and joint disorders (TMJD) are mild and self-limiting, about 10% of TMJD patients develop severe disorders associated with chronic pain and disability. It has been suggested that depression and catastrophizing contributes to TMJD chronicity. This article assesses the effects of catastrophizing and depression on clinically significant TMJD pain (Graded Chronic Pain Scale [GCPS] II–IV). Four hundred eighty participants, recruited from the Minneapolis/St. Paul area through media advertisements and local dentists, received examinations and completed the GCPS at baseline and at 18-month follow-up. In a multivariable analysis including gender, age, and worst pain intensity, baseline catastrophizing (β 3.79, P < 0.0001) and pain intensity at baseline (β 0.39, P < 0.0001) were positively associated with characteristic of pain intensity at the 18th month. Disability at the 18-month follow-up was positively related to catastrophizing (β 0.38, P < 0.0001) and depression (β 0.17, P = 0.02). In addition, in the multivariable analysis adjusted by the same covariates previously described, the onset of clinically significant pain (GCPS II–IV) at the 18-month follow-up was associated with catastrophizing (odds ratio [OR] 1.72, P = 0.02). Progression of clinically significant pain was related to catastrophizing (OR 2.16, P < 0.0001) and widespread pain at baseline (OR 1.78, P = 0.048). Results indicate that catastrophizing and depression contribute to the progression of chronic TMJD pain and disability, and therefore should be considered as important factors when evaluating and developing treatment plans for patients with TMJD.
The purpose of this study was to perform a retrieval analysis of temporomandibular joint (TMJ) al... more The purpose of this study was to perform a retrieval analysis of temporomandibular joint (TMJ) alloplastic interpositional implants and test possible correlation between implant failure features and patient clinical outcomes. In addition, we investigated the implants' surface and examined the foreign body reaction associated with different types of alloplastic materials.Twelve implants (Proplast/Teflon [Vitek, Houston, TX] and Silastic [Dow Corning, Midland, MI]) were surgically removed from the patients' TMJs. Implant surface failure features (fracture length, perforation of the implants) were observed using stereomicroscopy and recorded for description of the failure mechanisms and to statistically compare with clinical outcomes. Patients' clinical data (pain symptoms and mandibular function) were collected and examined. Clinical outcomes were obtained relative to symptom severity (Symptom Severity Index [SSI]) and jaw function (modified Mandibular Function Impairment Questionnaire [mMFIQ]). Peri-implant soft tissues and implants were analyzed with light microscopy and stereo zoom microscopy. Electron microprobe analysis of implant fragments and peri-implant tissues was performed.The statistical results showed that only the presence of implant perforation was statistically associated with the SSI, specifically with the pain tolerability dimension. No statistical association was seen between any of the other implant failure predictors and the SSI and between the predictors and the mMFIQ. Stereo zoom microscopy suggested that Proplast/Teflon implants (n = 7) were susceptible to perforation, layer tearing, fracture and fiber extrusion. The Silastic implants (n = 3) revealed a possible center perforation with fracture lines towards the periphery and fiber extrusion. Teflon implant wear debris particles appear to trigger a multinucleated giant cell foreign body reaction.Facial pain was a significant correlate to perforation and breakdown of the alloplastic TMJ interpositional implants, and most likely was the reason for implant removal.
Teledentistry is an exciting new area of dentistry that fuses electronic health records, telecomm... more Teledentistry is an exciting new area of dentistry that fuses electronic health records, telecommunications technology, digital imaging, and the Internet to link health providers in rural or remote communities. For the patient located in underserved or remote areas, teledentistry improves ready access to preventive dental care and teleconsultation with specialists. It allows the dentist in the nearby community to provide easier access to preventive care to a patient who, otherwise, probably will not seek care. It enables the specialist located many miles away to make a diagnosis and recommend treatment options and/or referral.
Although most cases of temporomandibular muscle and joint disorders (TMJD) are mild and self-limi... more Although most cases of temporomandibular muscle and joint disorders (TMJD) are mild and self-limiting, about 10% of TMJD patients develop severe disorders associated with chronic pain and disability. It has been suggested that fibromyalgia and widespread pain play a significant role in TMJD chronicity. This paper assessed the effects of fibromyalgia and widespread pain on clinically significant TMJD pain (GCPS II-IV). Four hundred eighty-five participants recruited from the Minneapolis/St. Paul area through media advertisements and local dentists received examinations and completed the Graded Chronic Pain Scale (GCPS) at baseline and at 18 months. Baseline widespread pain (OR: 2.53, P = .04) and depression (OR: 5.30, P = .005) were associated with onset of clinically significant pain (GCPS II-IV) within 18 months after baseline. The risk associated with baseline fibromyalgia was moderate, but not significant (OR: 2.74, P = .09). Persistence of clinically significant pain was related to fibromyalgia (OR: 2.48, P = .02) and depression (OR: 2.48, P = .02). These results indicate that these centrally generated pain conditions play a role in the onset and persistence of clinically significant TMJD.Fibromyalgia and widespread pain should receive important consideration when evaluating and developing a treatment plan for patients with TMJD.
The adequacy of a training program intended to calibrate examiners of temporomandibular disorders... more The adequacy of a training program intended to calibrate examiners of temporomandibular disorders (TMD) was evaluated. Eight examiners blindly rated 12 subjects with various TMD signs and symptoms after participating in a 5-h intense training procedure. Some examiners had earlier experience of TMD examinations, and some were newly trained. The Craniomandibular Index was used as the assessment instrument. Agreement within the whole group of examiners was low. Training tended to increase the probability of correctly registering signs. It is concluded that the program was not sufficient to create reliability among multiple examiners. More extensive training, not only to a standard but also between the different examiners, appears necessary. Revision of the examination technique is suggested, and recommendations for strengthening the calibration procedures are made.
Page 1. Myogenous Temporomandibular Disorders: Diagnostic and Management Considerations James Fri... more Page 1. Myogenous Temporomandibular Disorders: Diagnostic and Management Considerations James Fricton, DDS, MS Diagnostic and Biological Sciences, University of Minnesota School of Dentistry, 6-320 Moos, Minneapolis, MN 55455, USA ...
The CMI appears to be valid for use in clinical studies, but users must be aware of its numerous ... more The CMI appears to be valid for use in clinical studies, but users must be aware of its numerous potential errors and its associated strict methodologic guidelines to ensure accuracy and reproducibility of results. The subjective nature of some items demands that the same rater who is unaware of the management status of the patient perform both evaluations. If multiple raters are used, it is recommended that the raters discuss all items, and compare scoring of demonstration subjects before the study and use a pressure algometer for muscle palpation.
The Craniomandibular Index (CMI) was developed to provide a standardized measure of severity of p... more The Craniomandibular Index (CMI) was developed to provide a standardized measure of severity of problems in mandibular movement, TMJ noise, and muscle and joint tenderness for use in epidemiological and clinical outcome studies. The instrument was designed to have clearly defined objective criteria, simple clinical methods, and ease in scoring; it is divided into the Dysfunction Index and the Palpation Index. Inter-rater reliability (three raters) and intra-rater reliability (19 patients examined twice by one rater) were tested to determine whether the instrument has operational definitions sufficiently precise to allow for consistency in use between different raters and with one rater over time. Intraclass Correlation Coefficient for inter-rater reliability was 0.84 for the Dysfunction Index, 0.87 for the Palpation Index, and 0.95 for the CMI. Correlation for intra-rater reliability was 0.92 for the Dysfunction Index, 0.86 for the Palpation Index, and 0.96 for the CMI. These results support the reliability of the CMI for use in epidemiological and clinical studies. Users are cautioned about the subjectivity of numerous items within the CMI and the strict methodological guidelines that must be followed in order to assure accuracy and reproducibility of results.
Abstract Epidemiological investigations about the prevalence of TMJ ID and osteoarthritis have la... more Abstract Epidemiological investigations about the prevalence of TMJ ID and osteoarthritis have largely reported the symptoms and signs associated with these disorders without specific criteria to establish the diagnosis. In this study, specific diagnostic criteria have been developed, using historical, clinical and tomographic items that are predictive of the presence and stage of TMJ internal derangement. The diagnostic criteria were compared to arthrotomography to assess their diagnostic accuracy. Overall, the percent agreement was 75%. The predictability of specific stages of TMJ ID varied. Overall, sensitivity and specificity of the criteria were acceptable. The diagnosis of osteoarthritis was predicted only with tomography. Utilization of these diagnostic criteria in epidemiological studies is valid due to their high overall predictiveness when applied to a large population
Masticatory myofascial pain is a relatively frequent occurrence in patientsseen by the orthodonti... more Masticatory myofascial pain is a relatively frequent occurrence in patientsseen by the orthodontist. Thus it is important to understand the management of this condition. Treatment is generally directed toward the restoration of a more physiological state in the muscles of mastication and involves medications, appliances, various forms of behavioral modification, as well as the use of muscle exercises and trigger point therapy. This article focuses on the role of the latter modalities in the management of myofascial pain and dysfunction.
The efficacy of two hypnotic induction techniques on twenty subjects whose degree of hypnotic sus... more The efficacy of two hypnotic induction techniques on twenty subjects whose degree of hypnotic susceptibility had been previously determined as either high or low was compared. The two induction techniques, direct and indirect, reflected a difference in permissiveness of language, use of imagery and symbolic language, the use of the subject's experience and the perceived control by the subject. Pain threshold measures, induced by electrical tooth pulp stimulation, were assessed before, during, and after induction of hypnotic analgesia. Analysis of the data showed that the indirect technique was significantly more effective than the direct technique in changing pain thresholds regardless of susceptibility. The direct technique was significantly effective with only those subjects who received high susceptibility scores. Although interpretation of results is limited due to small sample size, the findings suggest that patients with low hypnotic susceptibility, as measured by conventional tests, may still be able to achieve useful hypnotic analgesia.
Atypical facial pain is a persistent pain in the face or intraoral region that does not fit into ... more Atypical facial pain is a persistent pain in the face or intraoral region that does not fit into the diagnostic criteria associated with specific orofacial pain disorders. This article presents the results of a study, which showed that in most cases of presumed atypical facial pain, there is a specific physical diagnosis or multiple diagnoses that causes the persistent pain. These difficult to diagnose disorders are reviewed with discussion of future research that is needed in this area.
Although most cases of temporomandibular muscle and joint disorders (TMJD) are mild and self-limi... more Although most cases of temporomandibular muscle and joint disorders (TMJD) are mild and self-limiting, about 10% of TMJD patients develop severe disorders associated with chronic pain and disability. It has been suggested that depression and catastrophizing contributes to TMJD chronicity. This article assesses the effects of catastrophizing and depression on clinically significant TMJD pain (Graded Chronic Pain Scale [GCPS] II–IV). Four hundred eighty participants, recruited from the Minneapolis/St. Paul area through media advertisements and local dentists, received examinations and completed the GCPS at baseline and at 18-month follow-up. In a multivariable analysis including gender, age, and worst pain intensity, baseline catastrophizing (β 3.79, P < 0.0001) and pain intensity at baseline (β 0.39, P < 0.0001) were positively associated with characteristic of pain intensity at the 18th month. Disability at the 18-month follow-up was positively related to catastrophizing (β 0.38, P < 0.0001) and depression (β 0.17, P = 0.02). In addition, in the multivariable analysis adjusted by the same covariates previously described, the onset of clinically significant pain (GCPS II–IV) at the 18-month follow-up was associated with catastrophizing (odds ratio [OR] 1.72, P = 0.02). Progression of clinically significant pain was related to catastrophizing (OR 2.16, P < 0.0001) and widespread pain at baseline (OR 1.78, P = 0.048). Results indicate that catastrophizing and depression contribute to the progression of chronic TMJD pain and disability, and therefore should be considered as important factors when evaluating and developing treatment plans for patients with TMJD.
The purpose of this study was to perform a retrieval analysis of temporomandibular joint (TMJ) al... more The purpose of this study was to perform a retrieval analysis of temporomandibular joint (TMJ) alloplastic interpositional implants and test possible correlation between implant failure features and patient clinical outcomes. In addition, we investigated the implants' surface and examined the foreign body reaction associated with different types of alloplastic materials.Twelve implants (Proplast/Teflon [Vitek, Houston, TX] and Silastic [Dow Corning, Midland, MI]) were surgically removed from the patients' TMJs. Implant surface failure features (fracture length, perforation of the implants) were observed using stereomicroscopy and recorded for description of the failure mechanisms and to statistically compare with clinical outcomes. Patients' clinical data (pain symptoms and mandibular function) were collected and examined. Clinical outcomes were obtained relative to symptom severity (Symptom Severity Index [SSI]) and jaw function (modified Mandibular Function Impairment Questionnaire [mMFIQ]). Peri-implant soft tissues and implants were analyzed with light microscopy and stereo zoom microscopy. Electron microprobe analysis of implant fragments and peri-implant tissues was performed.The statistical results showed that only the presence of implant perforation was statistically associated with the SSI, specifically with the pain tolerability dimension. No statistical association was seen between any of the other implant failure predictors and the SSI and between the predictors and the mMFIQ. Stereo zoom microscopy suggested that Proplast/Teflon implants (n = 7) were susceptible to perforation, layer tearing, fracture and fiber extrusion. The Silastic implants (n = 3) revealed a possible center perforation with fracture lines towards the periphery and fiber extrusion. Teflon implant wear debris particles appear to trigger a multinucleated giant cell foreign body reaction.Facial pain was a significant correlate to perforation and breakdown of the alloplastic TMJ interpositional implants, and most likely was the reason for implant removal.
Teledentistry is an exciting new area of dentistry that fuses electronic health records, telecomm... more Teledentistry is an exciting new area of dentistry that fuses electronic health records, telecommunications technology, digital imaging, and the Internet to link health providers in rural or remote communities. For the patient located in underserved or remote areas, teledentistry improves ready access to preventive dental care and teleconsultation with specialists. It allows the dentist in the nearby community to provide easier access to preventive care to a patient who, otherwise, probably will not seek care. It enables the specialist located many miles away to make a diagnosis and recommend treatment options and/or referral.
Although most cases of temporomandibular muscle and joint disorders (TMJD) are mild and self-limi... more Although most cases of temporomandibular muscle and joint disorders (TMJD) are mild and self-limiting, about 10% of TMJD patients develop severe disorders associated with chronic pain and disability. It has been suggested that fibromyalgia and widespread pain play a significant role in TMJD chronicity. This paper assessed the effects of fibromyalgia and widespread pain on clinically significant TMJD pain (GCPS II-IV). Four hundred eighty-five participants recruited from the Minneapolis/St. Paul area through media advertisements and local dentists received examinations and completed the Graded Chronic Pain Scale (GCPS) at baseline and at 18 months. Baseline widespread pain (OR: 2.53, P = .04) and depression (OR: 5.30, P = .005) were associated with onset of clinically significant pain (GCPS II-IV) within 18 months after baseline. The risk associated with baseline fibromyalgia was moderate, but not significant (OR: 2.74, P = .09). Persistence of clinically significant pain was related to fibromyalgia (OR: 2.48, P = .02) and depression (OR: 2.48, P = .02). These results indicate that these centrally generated pain conditions play a role in the onset and persistence of clinically significant TMJD.Fibromyalgia and widespread pain should receive important consideration when evaluating and developing a treatment plan for patients with TMJD.
The adequacy of a training program intended to calibrate examiners of temporomandibular disorders... more The adequacy of a training program intended to calibrate examiners of temporomandibular disorders (TMD) was evaluated. Eight examiners blindly rated 12 subjects with various TMD signs and symptoms after participating in a 5-h intense training procedure. Some examiners had earlier experience of TMD examinations, and some were newly trained. The Craniomandibular Index was used as the assessment instrument. Agreement within the whole group of examiners was low. Training tended to increase the probability of correctly registering signs. It is concluded that the program was not sufficient to create reliability among multiple examiners. More extensive training, not only to a standard but also between the different examiners, appears necessary. Revision of the examination technique is suggested, and recommendations for strengthening the calibration procedures are made.
Page 1. Myogenous Temporomandibular Disorders: Diagnostic and Management Considerations James Fri... more Page 1. Myogenous Temporomandibular Disorders: Diagnostic and Management Considerations James Fricton, DDS, MS Diagnostic and Biological Sciences, University of Minnesota School of Dentistry, 6-320 Moos, Minneapolis, MN 55455, USA ...
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