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Temporomandibular Joint Disorders in Patients with Skeletal Discrepancies

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Temporomandibular Joint Disorders in Patients with Skeletal Discrepancies TEMPOROMANDIBULAR JO INT DISORDERS IN PATIENT S WITH SKELETAL DISCREPANCI ES SALMA AL-RIYAMI B.D.S (University of Bristol) M.Sc (University of London) Submitted for The Degree of Doctor in Philosophy in Clinical Dentistry (Orthodontics) UCL Eastman Dental Institute for Oral Health Sciences 2010 i ―I, Salma Al-Riyami confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis‖ London, 19th November 2010 Salma Al-Riyami ii Abstract Chapter I Literature review on the Temporomandibular joint (TMJ) and Temporomandibular disorders (TMD) Chapter II Systematic review of TMD in orthognathic patients This review was conducted to investigate the prevalence of temporomandibular joint dysfunction (TMD) in orthognathic patients and to determine the effect of the surgical intervention on the status of the temporomandibular joint (TMJ). A methodological process was applied for study selection, data management and quality assessment and meta-analyses were conducted where appropriate. This review identified 53 papers for inclusion and there was heterogeneity in the diagnosis and classification of TMD between the studies. Patients undergoing orthognathic treatment for the correction of dentofacial deformity and suffering from TMD appeared more likely to see an improvement in their signs and symptoms than deterioration, particularly with respect to pain related symptoms. This information should be given to prospective patients during the consent process, but it should be stressed that no guarantees can be made. Chapter III TMD in orthognathic patients and a control group with no skeletal discrepancies Sixty eight orthognathic patients and 72 control subjects (with no anterior-posterior, vertical or transverse discrepancies) were recruited for this section of the PhD. Self- reported symptoms and clinical signs of TMD were recorded and compared between the two groups. A significant difference in TMD prevalence was observed between the controls (27.8%) and patients (44.1%), with the patients being more susceptible to TMD. However, although orthognathic patients appear more likely to suffer from TMD, whether treatment improves their TMJ condition is highly questionable. This issue should be highlighted in any informed consent process. iii Chapter IV A longitudinal study of TMD in orthognathic patients Twenty orthognathic patients were followed longitudinally throughout treatment to establish whether TMD signs and symptoms altered during the course of treatment. Although no significant differences were found when comparing the pre-treatment (T1) findings with those prior to surgery (T2), sufficient individual changes in TMD signs and symptoms were observed to question the suitability of the ―prior to surgery‖ time point as a baseline for comparisons in future studies. When comparing pre (T1) and post-treatment (T3) TMD changes, no significant differences were observed. This study supports the theory that TMD is a dynamic condition and signs and symptoms are likely to fluctuate throughout treatment. However, the small sample size in this study was clearly a limiting factor. Chapter V TMJ information course: Comparison of the instructional efficacy of an internet-based TMJ tutorial with a traditional face-to-face seminar A TMJ tutorial was developed on a virtual learning environment (VLE) to enable students to enhance their examination and diagnostic skills and a randomised cross-over trial was then conducted. Thirty postgraduate students were recruited as participants and the success of this mode of teaching was compared with a conventional face-to-face seminar. This study found that both modes of teaching were equally effective in delivering information to students but teaching the topic twice enhanced the retention of knowledge. In addition the students reported positive perceptions of VLE learning and the feedback for this mode of teaching was comparable with traditional methods of teaching. iv Publications Resulting from this Research 1. Al-Riyami S, Moles DR, Cunningham SJC (2009) Orthognathic treatment and temporomandibular disorders: A systematic review. Part 1. A new quality-assessment technique and analysis of study characteristics and classifications. Am J Orthod Dentofacial Orthop. 136:624.e1-624.e.15. (Appendix II) 2. Al-Riyami S, Cunningham SJC, Moles DR (2009) Orthognathic treatment and temporomandibular disorders: A systematic review. Part 2. Signs and symptoms and meta-analyses. Am J Orthod Dentofacial Orthop. 136:626.e1-624.e.16. (Appendix II) 3. Al-Riyami S, Moles DR, Cunningham SJC Comparison of the instructional efficacy of an internet-based temporomandibular joint (TMJ) tutorial with a traditional seminar. Accepted for publication by the British Dental Journal, April 2010. Manuscript reference: MSS-2009-721R (Appendix II) v Acknowledgments It is with my sincerest gratitude that I take this opportunity to thank those, without whom, this PhD thesis would not have been possible. I am truly and deeply indebted to so many people that there is no way to acknowledge them all or even any of them properly. I sincerely hope that everyone who knows that they have contributed towards achieving my goals feels the satisfaction that they have helped, and that they do not feel remorse that I have not ungratefully omitted them from explicit mention. Firstly, I thank my primary supervisor Dr. Susan Cunningham whose encouragement, supervision and guidance from the preliminary to the concluding level of this thesis has been endless. Her continuous support throughout this PhD has enabled me to complete the task ahead. She so selflessly gave up so much of her time reading and reviewing the many drafts and chapters, and for that I am forever grateful. Dr. Cunningham has been so much more than just the perfect supervisor; she has been a mentor, teacher and friend. Special thanks goes to my secondary supervisor, Professor David Moles, for helping me complete the writing of this dissertation as well as the challenging research that lies behind it. He has always been at hand to listen and to give advice and has showed me different ways to approach a research problem and the need to be persistent to accomplish any goal. I am truly fortunate to have been able to enjoy and benefit from such a relationship. Professor Nigel Hunt, for his support throughout my study at the Eastman Dental Institute. It has been a great privilege to have the opportunity to study at the Eastman and work with him. I have to thank Dr. Rachel Leeson for sharing her wisdom on the subject, and for so graciously giving up so much of her time to help develop the educational components of this research. Her dedication went above and beyond the call of duty. vi I am deeply indebted to Dr Derren Ready, for his support and kindness, and I am very thankful to the Eastman Dental Institute, Microbiology department, for being the best volunteers any one could have asked for. A special note of gratitude is reserved for my orthodontic graduate colleagues, whom I have worked with over the course of this research study. Their support has been invaluable, and I am eternally grateful to them all for giving up their time at various points throughout this study. I would also like to thank Dr. Stephen Davies for his very fine introduction to the topic, and for hosting me at the Manchester University Dental School. My thanks go to the many people at UCL who helped and encouraged me during my time here, including but not limited to Patrick Robinson, Desmond and the rest of the UCL multimedia department for their fine work and skill in creating an incredible presentation. Additionally, the UCL LTSS department for developing my Moodle skills. I have been extremely fortunate to share an office with some of the best people. I have to thank all my officemates not only for benefiting from their intelligence, wit, humanity, and companionship, but also for all their patience and generosity. Let me also say ‗thank you‘ to all the consultants, clinical lecturers, nurses, laboratory staff and others in the Orthodontic Department of the Eastman Dental Hospital, they have put up with me for the duration of my course, and without their support, my time at the Eastman would have been miserable. I would also like to say a special thank you to Annette Robinson, who never failed to keep me updated about the comings and goings of patients. None of this would have also been possible without the help and support of the library and support staff of the Eastman Dental Institute; Andy, Marianne Dang, the Information Technology department and the countless others. I offer my regards and blessings to all of those who helped me in any respect during the completion of this research, and would like to thank all my great friends that vii have been a backbone of support. Without your encouragement and sometimes distractions, this thesis would never have been completed. Last, but not least, I thank my family especially my father (may his soul rest in peace) and my mother Asma, for educating me, for her unconditional support and encouragement to pursue my interests and for believing in me. My sister Aisha, for listening to my complaints and frustrations and being such wonderful company throughout my time in London. My brother Sultan for his wisdom and remarkable sense of humour. Without the love and support of my husband Amin, I would be nowhere. Thank you all for being a part of my life. viii Table of Contents Title...............................................................................................................i
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