|Year : 2013 | Volume
| Issue : 1 | Page : 26-31
Temporomandibular disorders: Biobehavioral assessment
Sandeep Kumar Bains1, Archana Bhatia2, Harkanwal Preet Singh3, Madhulika Yadav4
1 Department of Oral Medicine, Diagnosis and Radiology, Swami Devi Dayal Dental College and Hospital, Barwala, Panchkula, Haryana, India
2 Department of Periodontology and Implantology, Dashmesh Institute of Dental Sciences, Faridkot, Punjab, India
3 Departments of Oral and Maxillofacial Pathology and Microbiology, Swami Devi Dayal Dental College and Hospital, Barwala, Panchkula, Haryana, India
4 Department of Pedodontics and Preventive Dentistry, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||23-May-2013|
Sandeep Kumar Bains
Department of Oral Medicine, Diagnosis and Radiology, Swami Devi Dayal Dental College and Hospital, Barwala, Panchkula, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The term "temporomandibular disorders (TMD)" is a collective term used to describe a group of musculoskeletal conditions occurring in the temporomandibular region These conditions are characterized by pain in the muscles of mastication, the temporomandibular joint, or both. Typically, treatment of TMD is driven largely by the physical diagnosis alone, without addressing the personal or psychological impact of TMD pain or the patterns of coping used for TMD patients. Although TMD is regarded by many as a condition in which psychosocial factors influence the course of the disease, little attention has been paid to assessing how psychological or psychosocial factors influence treatment outcome and whether successful clinical outcome is associated with improved psychosocial function. In this article, we are discussing the various methods commonly used for biobehavioral assessment.
Keywords: Biobehavioral, psychological, temporomandibular disorders
|How to cite this article:|
Bains SK, Bhatia A, Singh HP, Yadav M. Temporomandibular disorders: Biobehavioral assessment. ASL Muscuskel Dis 2013;1:26-31
| Introduction|| |
The temporomandibular joint (TMJ) is one of the most complex joints in the body and, at this joint, the mandible articulates with the cranium. 
The term "temporomandibular disorders" (TMD) is a collective term used to describe a group of musculoskeletal conditions occurring in the temporomandibular region (Laskin et al., 1983). These conditions are characterized by pain in the muscles of mastication, the TMJ, or both.  According to the American Society of Temporomandibular Joint Surgeons, TMD is a collective term embracing all the problems relating to TMJ and related musculoskeletal structures. 
In order to treat TMD, it is necessary to understand etiology and to establish a systematic procedure for differential diagnosis. The question is should we treat pain as a symptom or as a disease? When only the symptom of pain is treated, reoccurrence is highly probable, whereas, if the causes are eliminated, the prognosis of long-term relief is much more favorable. The psychological, emotional, and behavioral factors can have a potential impact on the treatment of TMD.
Fordyce et al., were the first to introduce the term chronic pain behaviors to emphasize that the management of chronic pain involves a rehabilitation rather than a cure model, that is, the objectives for the management of patients with chronic pain emphasize rehabilitating the patient to return to a useful and productive lifestyle and minimizing depression and other debilitating emotional states, rather than achieving a permanent cure for the pain. 
The term biobehavioral assessment includes assessment of patient's cognitive (i.e., thinking) and affective (i.e., emotional) status, as well as assessment of his or her current level of behavior (i.e., the extent to which behavior in social settings such as home, work, school, or when seeking TMD treatment, is adaptive or maladaptive), that is, the current level of psychosocial function. Moreover, biobehavioral assessment may point to expanded treatment possibilities that fall within the realm of behavioral and cognitive-behavioral therapies. Typically, treatment of TMD is driven largely by the physical diagnosis alone, without addressing the personal or psychological impact of TMD pain or the patterns of coping used for TMD patients.
In this article, we have discussed the various methods commonly used for biobehavioral assessment that may be included in the evaluation of TMD patients and may ultimately help in effective patient management.
| Methods of Assessing Biobehavior|| |
Several methods have evolved for biobehavioral assessment of patients with chronic pain conditions. Most of these methods are reliable and valid for assessing other chronic pain conditions rather than for assessing TMD. However, TMD shares many biobehavioral characteristics with other common chronic pain conditions, and it is reasonable to assume that methods applicable to those conditions may be applicable to TMD as well. The four most widely used approaches to biobehavioral assessment of chronic pain patients are self-monitoring, self-report, multiaxial, and observational.
| Self-Monitoring Methods|| |
Self-monitoring has been used extensively for decades for a wide variety of clinical problems, and its clinical uses are limited only by the imagination of the clinician and the cooperation of the patient. Its implementation can range from a request from the clinician to observe a simple phenomenon to a multicolumn table that lists time of day, pain intensity, mood state, cognitions, and behaviors over the preceding 30 min, to be completed by the patient after each pain episode for 2 weeks. Self-monitoring was first used for TMD patient assessment to record parafunctional behaviors. 
| Observational Methods|| |
Fordyce was the first to introduce direct observation of pain-related physical behaviors by the management of chronic back pain; it was then extended and formalized by him into reliable and valid scales for measuring the impact of pain on physical movement.  LeResche and Dworkin  developed methods for reliably observing and coding facial behavior for pain. Based on a survey of current literature, it can be rightfully concluded that direct observational measures of TMD patients for biobehavioral assessment are not as well developed as the widely used self-report measures. 
| Self-Report Methods|| |
The self-report methods include the use of symptom checklists; interview schedules; emotional status, psychological adaptation, coping behaviors psychological, and biobehavioral rating scales; and psychological tests assessing mental and healthcare utilization. It includes the following.
Fricton et al., at the University of Minnesota developed IMPATH Scale for TMD. It is an interactive computer-based assessment instrument used as screening and personal history instrument.  It has the advantage of instantaneous feedback. It may serve as a useful guide for clinicians wishing to obtain a clinical impression of how their patients are doing psychologically and biobehaviorally.
The TMJ scale , was developed as a self-report measure for use in the home or office and assesses three domains: Physical, psychosocial, and global. The physical domain includes assessment of pain, and the psychosocial domain assesses psychological factors and stress. The scale, which has reportedly been used quite extensively, requires scoring and interpretation by its developers. It yielded information that may be useful for clinicians treating TMD, although some questions about its validity as a psychosocial assessment tool have been noted by Rugh et al.,  and byPrkachin  as well as by others. Findings from the TMJ scale indicate that women with TMD report a higher level of severity of all physical and psychological symptoms as compared with men, and a relationship between severity of psychological problems and chronicity of TMD has been noted. Senstivity and specificity of test range from 88% to 93%. 
Keefe and Gill  developed a well-known and widely used measure of pain coping, indicating that passive coping strategies, particularly catastrophizing and praying, seem to be common among those who respond less well, biobehaviorally and emotionally, to their chronic pain problems. Supporting data comes from the use of measure developed by Brown and Nicassio  that indicates that those who use active rather than passive pain coping styles and those who perceive themselves as having some control over their pain conditions remain better able to minimize the personal and psychological negative impact.
Illness behavior and sickness impact measures
The Illness Behavior Questionnaire (IBQ) by Pilowsky  and the Sickness Impact Profile (SIP) by Bergner and associates  were developed for assessing the psychological and biobehavioral impact of illness beliefs. These measures have provided useful information about biobehavioral adaptation to chronic pain, including disability associated with chronic pain conditions and differences in beliefs and expectations between pain clinic populations and chronic pain patients seeking treatment elsewhere. The IBQ is a self-administered questionnaire that uses a yes/no response format. The original version contained 52 questions, later expanded to a 62-item version. A 30-item abbreviation has also been used. Ten of the questions were taken from the Whiteley Index of Hypochondriasis. The IBQ is introduced to the patient as a survey containing "a number of questions about your illness and how it affects you."  The results of these measures have appeared in the TMD literature, , supporting the conclusion that for a significant minority of clinical cases, TMD has an appreciable impact on personal functioning, but neither the IBQ nor the SIP is in common use by TMD clinicians and researchers.
Multidimensional pain inventory (MPI)
Turk  and Bergner  developed the MPI, perhaps the most widely used self-report measure, to assess the biobehavior and cognitive responses of patients with TMD and chronic pain. Unlike the IMPATH and TMJ scales, its use is not limited to patients with TMD, and it has been extensively investigated for its psychometric properties, demonstrating acceptable levels of reliability, validity and predictability of pain response pattern. The measure has been found to yield three distinct patient clusters that appear consistently across diverse chronic pain conditions, including back pain, headache, and TMD. The MPI is a self-report, 51-item inventory with the same eleven scales as in the original US version: Pain severity, interference due to pain, life control, affective distress (synonymously described as negative mood), support, punishing responses, solicitous responses, distracting responses, social and recreational activities, household chores, and activities away from home. The last three subscales can be summarized into one subscale of general activities. Cronbach's alpha reliability coefficients vary between α= 0.63-0.93, and test-retest reliability scores ranged from r p =0.46-0.93. ,
Minnesota multiphasic personality inventory
Perhaps the most widely used instrument for psychological status, the MMPI is not intended as a diagnostic instrument, rather provides a personality profile of psychological function. The test is long and takes highly specialized training to interpret; therefore, its use is not suitable for many clinicians. Standardization samples used for MMPI scale construction are reported in several independent studies as not being appropriate for chronic pain patients. However, using clustering methods to identify MMPI scale profiles that characterize pain patients, including TMD patients, has proved somewhat more useful. Generally, whether using the MMPI or more recently revised and restandardized MMPI-2, elevations on scales 1, 2, and 3-hypochondriasis, depression, and hysteria-were associated with the perceptions of severe pain, affective disturbance, and maladaptive patterns of psychological functioning. 
The MMPI has been used in many studies of TMD patients, and these studies support the conclusion that clinical psychopathology is present in an appreciable number of TMD patients presenting for treatment.  MMPI may be potentially more useful if the patient is referred to a psychologist for administration and interpretation of test results.
The SCL-90-R  is a 90-item symptom checklist that yields several scales, the most relevant of which are scales assessing depression, anxiety, and somatization. The SCL-90-R is much briefer than MMPI, but its overall usefulness with chronic pain patients has not been unequivocally established; some problems have emerged related to its use in chronic pain populations. For example, there has been difficulty in replicating the original 10-factor structure of the entire SCL-90-R, as observed by Derogatis.  Nevertheless, the SCL-90-R has been used extensively to study all types of chronic pain populations, including TMD. SCL-90-R has been standardized and its reliability (Cronbach's α) for total items is 0.97. 
| Multiaxial Diagnostic and Assessment Methods|| |
Methods that seek to integrate physical and biobehavioral factors into a multiaxial diagnostic and assessment instrument have been developed in recognition of the well-established relationship among physical, behavioral, and psychological factors.
The International Association for the Study of Pain Classification of Chronic Pain and Description of Chronic Pain Syndromes  uses five axes applicable in the assessment of all chronic pain conditions. Axis I is used to record the body region in which the pain sites occur; axis II designates the physiologic system (e.g., musculoskeletal, cutaneous, nervous) that is functioning abnormally and gives rise to pain; axis III reflects temporal characteristics and patterns of occurrence (e.g., single episode, continuous, fluctuating); axis IV captures the patient's statement of pain intensity and time since onset (e.g., mild: Of ≤1 month duration, severe: Of >6 months duration); and axis V is reserved for etiology and includes dysfunctional and psychological origin categories as well as designation of the etiology as genetic, inflammatory, and so on.
Research diagnostic criteria FOR TMD (RDC/TMD) 
The RDC/TMD guidelines provided standardized criteria for a two-axis diagnosis. This means that, along with a physical diagnosis (axis I), the patient receives a psychosocial diagnosis as well (axis II).
The axis I of the RDC/TMD classification system is a clinically based assessment taking into account for both anamnestic and clinical parameters of evaluation. It provides criteria for the diagnosis of three main groups of disorders: Muscles disorders (group I), disc displacements (group II), and other joint disorders, such as arthralgia, osteoarthritis, and osteoarthrosis (group III).
As for psychosocial diagnosis (axis II), a rating of jaw disability, chronic pain, and depression is provided by the use of validated questionnaires, thus allowing assess to psychosocial aspects that have to be addressed at the therapeutic level.
- Muscle disorders (group I) are diagnosed on the basis of anamnestic reports of pain in the muscles of mastication and clinical assessments of pain at palpation of at least three out of 20 muscular sites in the facial area (ten for each side). The only distinction among muscle disorders is made when mouth opening is less than 40 mm. When criteria for group I diagnosis are satisfied, a diagnosis of myofascial pain has to be put, and it will be with or without restricted mouth opening on the basis of the jaw range of motion.
- The diagnostic group of disc displacements (group II) aims to detect conditions in which the TMJ disc is anteriorized with respect to the mandibular condyle. Three diagnostic subgroups are identified: Displacements with reduction and displacements without reduction, with or without restricted mouth opening. The main criteria to diagnose disc displacement with reduction is the presence of a click sound during jaw movements that has to reciprocal (audible during both jaw opening and jaw closing movements) and not fixed (audible at different stages of motion during the jaw opening and jaw closing movements). Disc displacement without reduction is diagnosed when a history of previous click sounds is accompanied by their absence at clinical assessment and by a deflection during jaw opening. When the mouth opening is less than 35 mm, a diagnosis of displacement without reduction with restricted mouth opening can be put, while a mouth opening of more than the cut-off value points toward the diagnosis of disc displacement without reduction without restricted mouth opening.
- The third group of diagnoses, arthralgia, osteoarthritis, and osteoarthrosis (group III) is based upon joint palpation, accordingly to the presence of pain at palpation and crepitation sounds, alone or combined.
The RDC/TMD guidelines do not allow a diagnosis of less frequent conditions or pathologies that do not show a clear origin and natural progression (such as traumatic injuries, neoplasm of condyle, acute traumatic injuries, polyarthritis, atypical facial pain, and headaches). They actually represent the standard of reference for TMD diagnosis and classification in the research setting, also allowing cross-cultural and multicenter comparisons both in patient and non-patient populations. 
The points of strength of the RDC/TMD classification (standardization of criteria, simple taxonomic groups), which have led to their wide diffusion among epidemiologists and researchers, are not so helpful in the clinical setting, where the use of a wider classification system providing etiopathogenetic information as well should be more indicated. 
This is the reason for the diffusion of the American Academy of Orofacial pain classification system as a widely adopted scheme for TMD assessment in the clinical setting. 
| Discussion|| |
TMDs, also referred to as craniomandibular disorders, consist of a group of pathologies affecting the masticatory muscles, the TMJ, and related structures. Numerous methods of assessing of TMDs have been documentated. Each method has its advantages and limitations. This review article has analyzed the various parameters to assess the TMD and have emphasized on the need to re-evaluate these parameters in order to obtain a reliable parameter, which gives the complete functional, physiological, and anatomical assessment of TMJ and its associated structures.
The IMPATH scale for TMD is an interactive, computer-based assessment instrument that is used for screening and personal history taking.  It has the advantage of instantaneous feedback, but unfortunately, the psychometric characteristics of its illness behavior components have not yet been well established. Based on a survey of current literature, it is right to conclude that direct observational measures of TMD patients for biobehavioral assessment are not as well developed as the widely used self-report measures.  SCL-90-R has been used extensively to study all types of chronic pain populations, including TMD. When comparing the responses of chronic pain and psychiatric populations, the chronic pain population was distinguished, in studies by Buckelew et al.,  by reports of psychological distress limited to somatic, as opposed to emotional or cognitive and symptoms of anxiety and depression. The chronic pain groups distinguished by the MPI are labeled adaptive copers, interpersonally stressed and dysfunctional and the three types reflect a continuum of increasing disability and pain-related psychosocial dysfunction. Numerous additional measures exist that assess diverse dimensions of the chronic pain experience. These include the Ways of Coping Checklist,  which measures coping with stress not specific to chronic pain; measures of daily stress used by Lennon et al. to study the psychosocial adaptation of TMD patients; and the Millon Biobehavioral Health Inventory, the Chronic Illness Problem Inventory, the Psychosocial Pain Inventory, and the pain beliefs questionnaire. , Reports using these measures, taken together, confirm the extent to which TMD can be disabling for an appreciable segment of TMD sufferers.
Using the MMPI in a study predicting response to treatment for TMD; McCreary et al.,  found that somatization was related to jaw function problems at long-term follow-up. They found that "somatization was a significant predictor of outcome" for chronic TMD patients and concluded that, "if treatment does not address this somatization process, there is an increased risk there will be no improvement."
The chronic pain groups distinguished by the MPI are labeled adaptive copers, interpersonally stressed and dysfunctional and the three types reflect a continuum of increasing disability and pain-related psychosocial dysfunction. Turk and Rudy  demonstrated that TMD patients characterized as dysfunctional show significantly elevated depression and reported significantly more physical symptoms than those TMD patients that the MPI categorizes as adaptive copers.
More recently, Rudy et al.,  used the MPI to assess the relative efficacy of a cognitive-behavioral treatment intervention compared with physical treatment involving the use of an intraoral occlusal splint. They presented evidence that dysfunctional versus adaptive copers and interpersonally stressed patients responded differentially to these treatments, supporting their conclusion that clinical treatment decisions for TMD patients should include not only assessment of biobehavioral status, but also assignment to treatment interventions specifically based on the assessed level of psychological function. Therefore, author emphasizes that the MPI is one of the most carefully designed and well-studied self-report measures for assessing biobehavioral and psychological functioning in TMDs and chronic pain patients.
Assessment of biobehavioral status facilitates the establishment of a positive and optimistic doctor-patient relationship, or therapeutic alliance, and allows a collaborative set to be formed. A collaborative set refers to a dentist and patient working toward the same objectives, commonly held expectations are developed concerning what is to be done and why. Although TMD is regarded by many as a condition in which psychosocial factors influence the course of the disease, little attention has been paid to assessing how psychological or psychosocial factors influence treatment outcome and whether successful clinical outcome is associated with improved psychosocial function. A great deal more research is needed before it is possible to adequately evaluate how biobehavioral interventions achieve their desired effects and which components of the multimodal approaches now in common use are most potent. This review covers the various methods for behavioural assessment of TMDs. However, other scales are also present, helping in the diagnosis of TMDs.
| Conclusion|| |
Numerous scales and methods may be useful in diagnosis and treating TMDs. Not even a single method fulfills all the criteria. Author suggests that new scale should be invented that includes sufficient items and that should be employed at large, thus help in diagnosis and treating TMDs. Perhaps of greatest interest is the need to develop treatment approaches tailored to both the physical and biobehavioral status of the patient, as recently advocated with the introduction of the RDC/TMD. Too often, well-documented resistance still accompanies a recommendation for the inclusion of psychologically based treatment for TMD. It is unfortunate if unhealthy and unwarranted negative misapprehensions prevent any TMD patient from being helped through the use of readily available, scientifically sound, and safe methods that integrate biomedical and biobehavioral treatments for TMD.
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