|Year : 2020 | Volume
| Issue : 3 | Page : 376-380
Comparison of clinical and magnetic resonance imagining data of patients with temporomandibular disorders
E Somay1, B Yilmaz2
1 Department of Oral and Maxillofacial Surgery, Dental Clinic of Baskent University Adana Research and Practice Hospital, Adana, Turkey
2 Department of Specialist in Oral and Maxillofacial Radiology, Dental Clinic of Baskent University Adana Research and Practice Hospital, Adana, Turkey
|Date of Submission||13-Sep-2019|
|Date of Acceptance||01-Nov-2019|
|Date of Web Publication||5-Mar-2020|
Dr. E Somay
Department of Oral and Maxillofacial Surgery, Baskent University Adana Dr. Turgut Noyan Research and Teaching Center, Adana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: There are important criteria in the diagnosis of temporomandibular disorders (TMDs). These become significant if supported by magnetic resonance imaging (MRI). Otherwise, these findings alone may not be sufficient to diagnose TMD. Aim: This study compared the relationship between clinical findings indicated by patient and physician and MRI results in the diagnosis of TMD. Materials and Methods: Clinical examinations were performed in patients suspected of TMD for pain, difficulty in mouth opening, masticatory muscle tenderness, deviation (during mouth opening), normal mouth opening, and presence of bruxism. The MRI findings of the patients were compared with the clinical examinations. Results: MRI and clinical examination data of 136 patients were examined. The results showed significant correlations between deviation, normal mouth opening, and MRI results of TMD (P < 0.05). No correlation was found between age groups and clinical findings of TMD. TMJ was determined in normal limits in 61% of MRI results. Conclusions: Except for deviation and normal mouth opening, complaints and clinical findings determined by the clinicians do not support TMD. This may be due to the subjective nature of the clinical findings, and MRI results are needed for precise results.
Keywords: Magnetic resonance imagining, masticatory muscles, temporomandibular disorders, temporomandibular joint
|How to cite this article:|
Somay E, Yilmaz B. Comparison of clinical and magnetic resonance imagining data of patients with temporomandibular disorders. Niger J Clin Pract 2020;23:376-80
|How to cite this URL:|
Somay E, Yilmaz B. Comparison of clinical and magnetic resonance imagining data of patients with temporomandibular disorders. Niger J Clin Pract [serial online] 2020 [cited 2020 Apr 7];23:376-80. Available from: http://www.njcponline.com/text.asp?2020/23/3/376/280035
| Introduction|| |
The term temporomandibular disorder (TMD) is defined as a group of diseases that affect temporomandibular joint (TMJ), masticatory muscles, and adjacent structures which are found approximately 5–12% of the general population.,, The characteristic symptoms of TMD are such as pain in preauricular area and masticatory muscles, joint noises, and limited movement of the jaw.
TMD is considered as endemic diseases because of high prevalence in the general population. However, the etiology of TMJ diseases is mostly unknown and the percentage of patients requiring medical treatment is quite low. It is necessary to determine whether the joint is associated with TMD to treat correctly.
The diagnosis of TMD is mainly based on clinical examination and radiological findings on MRI which provides valid and reliable radiological evaluation and is accepted as the gold standard. The advantage of MRI is that it provides detailed information about TMJ without exposing the patient to ionizing radiation.
However, all radiological findings should be supported by clinical findings. There is no consensus on classification and diagnostic criteria for TMD in adult epidemiological studies. Clinical examination findings of patients with complaints suggesting TMD may not be sufficient and reliable alone to diagnose TMD. If the physician knows which clinical symptoms should be supported by MRI when diagnosing TMD, it may be easier to determine treatment and predict prognosis.
This study aims to evaluate the relationship between TMD symptoms such as limited mouth opening, deviation and MRI results, parafunctional habits such as bruxism in our patients with complaints related to TMJ, to analyze the prevalence of TMD among adults in the Turkish subpopulation, and help to provide scientific contribution to diagnose correctly.
| Materials and Methods|| |
This study was approved by Baskent University Institutional Review Board (Project no: D-KA19/19) and supported by Baskent University Research Fund.
In this retrospective study, TMJ MRI and clinical examination findings of 136 patients (103 females and 33 males) with complaints of jaw pain and limited mouth opening who were admitted to Baskent University Adana Dr. Turgut Noyan Research and Teaching Center between 2011 and 2018 were evaluated. Clinical examination was performed by an experienced maxillofacial surgeon and MRI findings were evaluated by an experienced oral and maxillofacial radiologist.
Masticatory muscles tenderness, deviation, and maximum mouth openings were evaluated in the clinical examination of the patients. A restriction of jaw movements and bruxism behavior were noted for each patient. None of the patients had an MRI before and were older than 18 years with no systemic diseases.
Maximum mouth openings were determined by measuring the distance between the upper and lower central teeth with the caliper and the mouth opening of 35 mm or more were accepted as normal mouth opening.
In all subjects, TMD was determined by MRI (Magnetron “Harmony” Siemens, Erlangen, Germany). TMDs were classified regarding to disc displacement with reduction or without reduction according to MRI data of patients. Screening of TMJ clinical examinations, anamnesis, and MRI results were evaluated according to “Research Diagnostic Criteria for Temporomandibular Disorders.”
In the statistical analysis of the data, the general profile of the research was formed by examining the patients' complaints and clinical findings of the study group by using descriptive statistics using SPSS 25.00 package software. Age, gender, frequencies, and percentages of clinical findings and MRI results of TMD were examined. Independent sample t-test was used to investigate the statistically significant correlation (P = 0.05) of clinical findings on the mean of MRI results.
| Results|| |
In the present study, MRI results of 136 patients, 103 (73.7%) females, and 33 (24.3%) males were analyzed retrospectively. The patients were older than 18 years of age and the mean patient age was 37.13 (range 18–65) years. [Table 1] lists the gender and age groups of patients. Three age groups were established: 18–34 (group 1, young), 35–54 (group 2, middle-aged), 55 and above (group 3, older) years. In the age group 3 (11.4%), the number of patients Group 1, age 18–34 years; group 2, age 35–54 years; group 3, age 55–65 years.
Before the diagnosis of TMD, all the patients underwent a detailed clinical examination and then MRI was performed for each.
In this study, the most common clinical finding was normal mouth opening (64%), followed by pain (47.8%), presence of bruxism (45.6%), difficulty in mouth opening (33.8%), deviation (28.7%), masticatory muscle tenderness (19.9%), pain and difficulty in mouth opening (18.4%). There was significant correlations among MRI results and deviation (P = 0.006), normal mouth opening (P = 0.034) [Table 2].
There was no statistically significant correlation between clinical findings of TMD and age of group [Table 3].
According to MRI findings, unilateral disc displacement with reduction and unilateral disc displacement without reduction (14%) were detected most frequently in TMD distribution, followed by bilateral disc displacement with reduction (9.6%), and bilateral disc displacement without reduction (1.5%). Although clinical findings were observed in patients, TMJ was found to be within normal limits in 61% of MRI results [Table 4].
| Discussion|| |
TMDs are explained as pain and dysfunction in the temporomandibular system and its muscles, joints, and associated structures. Clinical and radiological evaluation should be performed together for the exact diagnosis and treatment of TMD.
MRI is the best method for diagnosing TMD, in addition to providing perfect routine static images, it can analyze disc position and condylar excursion throughout the dynamic process of mouth opening and closing by obtaining multiple static images in series.,,
A wide range of prevalence of TMD, 4–15%, has been reported in epidemiological studies of adults. This wide variation in prevalence reflects a lack of consensus regarding the taxonomy, classification, and diagnostic criteria for TMD.,,
It is reported in many types of research that TMD is most common between the ages of 20 and 40 years and higher prevalence in females than in males.,, Similarly, the mean age of the patients who applied to our clinic due to complaints of TMJ was 37.1 years and the prevalence of females was higher than males [Table 1]. Emotional stress and parafunctional habits are frequently seen in females during this period which may have led to this finding.
Although pain is one of the main findings in the diagnosis of TMD, it is stated in research about the Turkish population that TMJ is insufficient to reflect the internal irregularity and that MRI cannot replace the diagnosis of TMD. As a result of a study with a high prevalence of females, it was obtained that pain may be associated with TMD. Parallel to literature, pain is the major symptom of TMD, but it is not statistically significant in young and old groups and MRI is required in the diagnosis of TMD. In the present study, there was no significant relationship between pain and MRI results of TMD, which was determined at a rate of 47.8% [Table 2]. When evaluated in age groups, no correlation was found between pain and MRI findings of TMD [Table 3]. This result could be explained by pain perception and description may be subjective due to reflected pain, emotional stress, anxiety, education level, and may also be a symptom of another disease in the head and neck region.
When the present study was evaluated by means of clinical findings and age groups, there was no correlation between difficulty in mouth opening which was a subjective symptom described by patients and MRI results [Table 3]. In a previous study, the difficulty in mouth opening was statistically significant between TMD symptoms according to age groups due to stress. However, the age range of this previous study was 17–32, but in present study was 18–65 years. In this research, elderly patients could not describe the difficulty of mouth opening.
Two studies have shown that masticatory muscle tenderness was found to show significant relevance in patients with TMD. However, these studies did not include any factors other than muscle tenderness and the number of patient limited only with 20 female patients were evaluated in both studies., In contrast, the number of patients and the age range were higher in this research. Therefore, we think that masticatory muscle tenderness is a clinical finding of TMD but does not support the MRI findings and there was no correlation between TMD and MRI [Table 3]. Similarly, muscle tenderness is not sufficient for certain diagnosis of TMD. Personal factors, idiopathic pain, anxiety, unilateral chewing, and trauma history may affect clinical findings.
The main alteration in TMD cases is seen in mandibular movements. According to study of Melchior et al. the deviation during mouth opening was observed in patients with TMD, probably related to intra-articular morphological changes and muscle components. In contrast, the correlation between the property of TMD and occlusal factors was not significant for other authors. This difference may be due to the presence of the control group, the number of patients, and difference in the analysis method. In our results, there was a significant correlation between deviation and MRI results, and TMD was proved in both parameters [Table 2]. This clinical finding may be confirming MRI results because deviation was not dependent on subjective perception such as pain and could be determined by the physician.
Differences in mouth opening may be observed in TMD cases due to internal derangements. Although pain is not a direct proof of TMD, patients may have limited mouth opening due to pain. However, studies have reported that mouth opening is an indicator of TMD., In our study, normal mouth opening was found to be significant and correlated with the MRI findings of the patients [Table 2]. This may have been due to the high rate of disc displacement with reduction and focus on other subjective clinical findings.
There is no sufficient information about the relationship between bruxism and clinical symptoms of TMD. Although the authors do not provide conclusive evidence between bruxism and TMD, the presence of bruxism is a risk factor for TMD.,, MRI results of the patients who presented to our clinic with bruxism and TMD did not support the clinical findings. There was no correlation in age groups [Table 3]. Similar to this study, no statistically significant relationship was found between sleep bruxism and TMD pain in the Polish population aged 18–65 years. In a review article on this subject, it was reported that sensitivity to diagnosis of bruxism was low and there was a possibility of bias in the researches. Therefore, since there may be nonspecific symptoms in the relationship between TMD and the presence of bruxism, objective MRI results and verifiable results were evaluated, no significant correlation was observed [Table 2]. Additionally, different diagnosis techniques like electroencephalogram (EEG) and polysomnography may be required to support the presence of bruxism during sleep recently.,
The most common MRI finding was determined normal TMJ findings [Table 4]. In our opinion, this means that although the complaints of patients and clinical findings indicate TMD, MRI results do not confirm this situation. In a previous study, most of the TMD patients had normal MRI results and there was no dysfunction in TMJ. Some other authors stated that there was a significant relationship between TMJ clinical findings and MRI results, but TMJ pain was the main criteria in the research. Furthermore, in the literature, disc displacement with reduction was higher among disc displacements as expected., This may be the result of the fact that the number of the patients with normal mouth opening is high and patients could not show the mouth opening correctly due to pain or muscle tenderness.
| Conclusions|| |
TMD was most frequently seen in females and the ages of 18–34 years in this study. Unlike previous researches, pain, difficulty in mouth opening, masticatory muscle tenderness, presence of bruxism were not indicators in the diagnosis of TMD. If there is deviation during mouth opening, clinicians should consider TMD and MRI should be evaluated even in cases where normal mouth opening is determined.
Financial support and sponsorship
Baskent University Research Fund.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Manfredini D, Guarda-Nardini L, Winocur E, Piccotti F, Ahlberg J, Lobbezoo F. Research diagnostic criteria for temporomandibular disorders: A systematic review of axis I epidemiologic findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:453-62.
Barclay P, Hollender LG, Maravilla KR, Truelove EL. Comparison of clinical and magnetic resonance imaging diagnoses in patients with disk displacement in the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:37-43.
Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al
. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: Recommendations of the International RDC/TMD consortium network and orofacial pain special interest group. J Oral Facial Pain Headache 2014;28:6-27.
Okeson JP. Management of Temporomandibular Disorders and Occlusion-E-Book. Mosby; Lexington, Kentucky 2019.
Crincoli V, Di Comite M, Di Bisceglie MB, Fatone L, Favia G. Temporomandibular disorders in psoriasis patients with and without psoriatic arthritis: An observational study. Int J Med Sci Public Health 2015;12:341.
Dimitroulis G. Temporomandibular disorders: A clinical update. BMJ 1998;317:190-4.
McNeill C. Management of temporomandibular disorders: Concepts and controversies. J Prosthet Dent 1997;77:510-22.
Manfredini D, Bucci MB, Nardini LG. The diagnostic process for temporomandibular disorders. Stomatologija 2007;9:35-9.
Orsini MG, Kuboki T, Terada S, Matsuka Y, Yamashita A, Clark GT. Diagnostic value of 4 criteria to interpret temporomandibular joint normal disk position on magnetic resonance images. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:489-97.
Dimitroulis G, Dolwick MF, Gremillion HA. Temporomandibular disorders. 1. Clinical evaluation. Aust Dent J 1995;40:301-5.
Abolmaali ND, Schmitt J, Schwarz W, Toll DE, Hinterwimmer S, Vogl TJ. Visualization of the articular disk of the temporomandibular joint in near-real-time MRI: Feasibility study. Eur Radiol 2004;14:1889-94.
Badel T, Šimunković SK, Marotti M, Lovko SK, Kern J, Krolo I. Study of temporomandibular joint disorder in older patients by magnetic resonance imaging. Gerodontology 2012;29:e735-41.
Dworkin SF. Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:301-55.
Alarabawy RA, El Ahwal HM, El Sergany MA, Mehrez WW. Magnetic resonance imaging evaluation of temporo-mandibular joint disorders, criterial analysis and significance in comparison with arthroscopy. Egypt J Radiol Nucl Med 2016;47:467-75.
Santos KC, Dutra ME, Warmling LV, Oliveira JX. Correlation among the changes observed in temporomandibular joint internal derangements assessed by magnetic resonance in symptomatic patients. J Oral Maxillofac Surg 2013;71:1504-12.
LeResche L. Epidemiology of temporomandibular disorders: Implications for the investigation of etiologic factors. Crit Rev Oral Biol Med 1997;8:291-305.
Von Korff M, Dworkin SF, Le Resche L, Kruger A. An epidemiologic comparison of pain complaints. Pain 1988;32:173-83.
Macfarlane T, Glenny A, Worthington H. Systematic review of population-based epidemiological studies of oro-facial pain. J Dent 2001;29:451-67.
Lee YH, Lee KM, Auh Q, Hong JP. Magnetic resonance imaging-based prediction of the relationship between whiplash injury and temporomandibular disorders. Front Neurol 2018;8:725.
Chalkoo AH, Ahmad MB, Naikoo FA. Magnetic resonance imaging and ultrasonography in the diagnosis of temporomandibular joint internal derangements: A comparative study. J Indian Acad Oral Med Rad 2015;27:198-202.
Maixner W, Diatchenko L, Dubner R, Fillingim RB, Greenspan JD, Knott C, et al
. Orofacial pain prospective evaluation and risk assessment study–The OPPERA study. J Pain 2011;12:T4-T11.2.
Okeson JP. Joint intracapsular disorders: Diagnostic and nonsurgical management considerations. Dental Clin North Am 2007;51:85-103.
Akdaǧ O, Yıldıran G, Karameşe M. Patient symptoms and magnetic resonance imaging correlation in temporomandibular joint internal derangement. Turk J Med Sci 2018;48:1092-5.
Pinto GN, Grossmann E, Iwaki Filho L, Groppo FC, Poluha RL, Muntean SA, et al
. Correlation between joint effusion and morphology of the articular disc within the temporomandibular joint as viewed in the sagittal plane in patients with chronic disc displacement with reduction: A retrospective analytical study from magnetic resonance imaging. Cranio 2019:1-6. doi: 10.1080/08869634.2019.1582166. [Epub ahead of print]
Ahuja V, Ranjan V, Passi D, Jaiswal R. Study of stress-induced temporomandibular disorders among dental students: An institutional study. Natl J Maxillofac Surg 2018;9:147-54.
] [Full text]
Silveira A, Gadotti IC, Armijo-Olivo S, Biasotto-Gonzalez D, Magee D. Jaw dysfunction is associated with neck disability and muscle tenderness in subjects with and without chronic temporomandibular disorders. Biomed Res Int 2015;2015:512792.
Silveira A, Armijo-Olivo S, Gadotti IC, Magee D. Masticatory and cervical muscle tenderness and pain sensitivity in a remote area in subjects with a temporomandibular disorder and neck disability. J Oral Facial Pain Headache 2014;28:138-46.
Melchior Md, Mazzetto MO, Magri LV. Relation of painful TMD with the speech function: What are the possible characteristics of mandibular movements and the main symptoms reported? Codas 2019;31:e 20180161.
Aboalnaga A, Amer N, Elnahas M, Salah MF, Soliman S, El Dakroury A, et al
. Malocclusion and temporomandibular disorders: Verification of the controversy. J Oral Facial Pain Headache 2019;33:440-50.
Koh KJ, Park HN, Kim KA. Internal derangement as a predictor of provoked pain on mouth opening: A magnetic resonance imaging study. Imaging Sci Dent 2017;47:219-26.
Kitsoulis P, Marini A, Iliou K, Galani V, Zimpis A, Kanavaros P, et al
. Signs and symptoms of temporomandibular joint disorders related to the degree of mouth opening and hearing loss. BMC Ear Nose Throat Disord 2011;11:5.
Fernandes G, Franco A, Siqueira J, Gonçalves DA, Camparis CM. Sleep bruxism increases the risk for painful temporomandibular disorder, depression and non-specific physical symptoms. J Oral Rehabil 2012;39:538-44.
Jiménez-Silva A, Peña-Durán C, Tobar-Reyes J, Frugone-Zambra R. Sleep and awake bruxism in adults and its relationship with temporomandibular disorders: A systematic review from 2003 to 2014. Acta Odontol Scand 2017;75:36-58.
Berger M, Szalewski L, Szkutnik J, Ginszt M, Ginszt A. Different association between specific manifestations of bruxism and temporomandibular disorder pain. Neurol Neurochir Pol 2017;51:7-11.
Manfredini D, Landi N, Fantoni F, Segu M, Bosco M. Anxiety symptoms in clinically diagnosed bruxers. J Oral Rehabil 2005;32:584-8.
Koyano K, Tsukiyama Y, Ichiki R, Kuwata T. Assessment of bruxism in the clinic. J Oral Rehabil 2008;35:495-508.
Wurm MC, Behrends TK, Wüst W, Wiesmüller M, Wilkerling A, Neukam FW, et al
. Correlation between pain and MRI findings in TMD patients. J Craniomaxillofac Surg 2018;46:1167-71.
Emshoff R, Brandlmaier I, Bertram S, Rudisch A. Relative odds of temporomandibular joint pain as a function of magnetic resonance imaging findings of internal derangement, osteoarthrosis, effusion, and bone marrow edema. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:437-45.
De Farias J, Melo S, Bento P, Oliveira L, Campos P, De Melo D. Correlation between temporomandibular joint morphology and disc displacement by MRI. Dentomaxillofac Radiol 2015;44:20150023.
Almăşan OC, Hedeşiu M, Băciuţ G, Leucuţa DC, Băciuţ M. Disk and joint morphology variations on coronal and sagittal MRI in temporomandibular joint disorders. Clin Oral Investig 2013;17:1243-50.
[Table 1], [Table 2], [Table 3], [Table 4]