Association between primary dentition SCIENTIFIC ARTICLES wear and clinical temporomandibular dysfunction signs Curt Goho, DDSHerschel L. Jones, DDS

Abstract Dental wear facets often are considered indicators of temporomandibulardysfunction (TMD).Dental wear facets are commonin children, but their association with TMDsigns is unknown.A reproducible, clinical evaluation of TMDsigns for youngchildren showsno statistically significant association between primary dentition wear facets and clinical signs of TMD(P < 0.05). Wearfacets in youngchildren do not appear to warrant TMDevaluation Or treatment. (Pediatr Dent 13:263-66, 1991)

Introduction Interest in pediatric temporomandibular dysfunc- Materials and Methods tion (TMD) is increasing. The patient age for TMD Children age 3 through 6 years with complete pri- diagnosis and treatment is getting younger (Nilner and mary dentitions were used as both comparison and Lassing 1981; Ogura et al. 1985; Vanderas and Ranalli sample populations. Fifty children without wear facets 1989). Manypediatric dentists routinely evaluate TM function, and some advocate early treatment (Padamsee comprised the comparison population, and 50 children with wear faceting served as the sample population. et al. 1985). Patients with conditions affecting TMJ function or The TMJexhibits mature morphology and more than faceting (juvenile rheumatoid arthritis, hemifacial 50% of mature size upon complete eruption of the microsomia, trauma, cerebral palsy), who could not primary dentition (Nickel et al. 1988). After 5 years cooperate for dental examination, or who had an in- age, growth velocity diminishes significantly and the complete or mutilated dentition (oligodontia, extrac- TMJis sufficiently formed at an early age to be affected tions without proper space maintenance) were excluded by parafunctional habits. and grinding are parafunctional habits of- from the study. Population size requirements were de- termined using the formula for comparing two popula- ten implicated in TMD(Ramfjord 1961; Keith 1983; tion proportions for independent samples (Rosner 1990), Reding et al. 1966; Seligman 1988). Wear facets are with a = .05, and b = .4. suggested as indicators of these parafunctional habits Children were selected during clinic and school (Lindquist 1971; Ahmad1986; Cash 1988; Seligman et al. 1988; Rugh 1988). Wear faceting from bruxism is screening examinations. Consent for examination was commonin the primary dentition (Lindquist 1971) and obtained through written clinic consent forms and school is used to justify evaluation and treatment of suspected parental consent policy. The first 50 children meeting TMD(Kirveskari et al. 1989). However, a relationship the criteria for each study group were evaluated. Two between primary dentition wear and TMDsigns and observers were trained in examination techniques. Interrater reliability was evaluated with Cohen’s Kappa symptoms has not been shown (Bernal and Tsamtsouris (Dworkin 1988). 1986). The purpose of this study was to evaluate any Parameters from other studies (Helkimo 1974; association between wear faceting of the primary teeth Morawaet al. 1985; Ogura et al. 1985; Vanderas 1987; and objective, clinically measurable signs suggesting Riolo et al. 1988; Okeson 1989) were used as much as TMD. possible for comparison of data. However, to prevent false positive results, examination of young children This article is a work of the United States Governmentand must exclude ambiguous, uncomfortable, or prolonged maybe reprinted without permission. The authors are em- procedures. Therefore, intra-auricular TMJpalpation, ployees of the United States Armyat Fort Lewis, WA, and in intraoral pt~rygoid palpation, and subjective question- the Second Field Hospital in Bremerhaven,Germany. Opin- ing about symptoms were inappropriate. Because of ions expressed therein, unless otherwise specifically indi- these limitations, only objective, easily measurableclini- cated, are those of the authors. Theydo not purport to express cal signs associated with TMDwere evaluated. views of the United States Armyor any other Departmentor Agency of the United States Government.

PEDIATRIC DENTISTRY: SEPTEMBER/OCTOBER,1991 ~ VOLUME13, NUMBER5 263 The clinical examination evaluated the following: the comparison group (no wear), 14% presented with 1. Muscle (temporalis, masseter) sensitivity clinical TMDsigns. Of these, 10%had single signs and palpation 4%had multiple signs. Ten per cent had opening devia- 2. TMJ pain upon palpation during opening tion. Eight per cent had joint noise that was noted as a and closing "soft click." None of the comparison group exhibited 3. Deviation of upon opening limited opening, muscle pain, or TMJpain. 4. Maximumextent of opening In the study group (wear facets), all subjects exhib- 5. Joint noise upon opening ited wear into in either incisors, cuspids, or 6. Extent of dental wear. molars; 42% had wear into dentin in two groupings of primary teeth, 10%had wear in all three groupings of Patients were seated upright for examination (Okeson teeth, and 30%had severe wear in at least one subset of 1989). The examiner palpated the temporalis, masseter, teeth. and TMJbilaterally with gentle pressure (approximately Sixteen per cent presented with clinical TMD.signs. 32 ounces) with two fingers (Vanderas and Ranalli Of these, 10% had single signs and 6% had multiple 1989) while patients opened and closed their mouths signs. Fourteen per cent exhibited opening deviation (Dworkin 1988). Pain responses were categorized and 6%had joint noise that was noted as a "soft click." "none," "wincing or guarding," or "unsolicited com- One patient reported muscle pain upon palpation. None ment about pain" (Helkimo 1974; Egermark-Eriksson et of the dental wear group had any opening limitation or al. 1981; Nielsen et al. 1989). TMJpain (Figure). Joint noise was evaluated during opening and clos- ing, with the examiner’s ear within 5 cm of the TMJ. A stethoscope was not used due to the high incidence of PRIMARY DENTITION WEAR AND TMD SIGNS false positive noises recorded by the acuity of the stetho- scope (Okeson 1989; Nielsen et al. 1989). Joint noise evaluations were "none," "soft click," "crepitus," and 14 ...... "harsh grating" (Dworkin 1988). 12 t -,- P Opening deviation more than 2 mmfrom the midline R 10 plane was considered a positive finding (Egermark- ¥ 8 Erikkson et al. 1981; Nielsen et al. 1989). L Maximal opening was measured from maxillary cen- E tral incisor edge to mandibular central incisor edge. E Any in centric was added to the maximal opening figures (Ingervall 1971; Hanson and Sh1£1e sign Multiple Signs Deviation TMJnoise Muscle pain Nilner 1975; Nielsen et al. 1989; Okeson1989). Evalua- CLINICAL FINDINGS tion was either "normal" or "below normal limits." The lower limit for normal opening in this age group was ~ Control (no wear) ~ Study group (wear) considered 34 mm(Bernal and Tsamtsouris 1986). Figure.Prevalence of TMDsigns in primarydentitions with and Dental wear was evaluated using a simplification of without wear. the scale devised by Hanson and Nilner (1975) and Carlsson (1984). Primary incisors, primary canines, and Interrater reliability had a Kappaof 0.82 (N = 12). Chi- primary molars were evaluated as three groups. Evalu- square evaluation showed no statistically significant ation of wear was "none or enamel only," "dentin association betweenthe presence, severity of location of exposed," and "severe wear" (more than one third of wear and clinical signs of TMD.There was no statistical the abraded). Wear into dentin was considered difference in incidence of single or collective TMDsigns atypical wear faceting (Ramfjord et al. 1961). between the comparison and study populations of the Any single positive finding in the muscle, TMJ, or 95%confidence level. opening criteria categorized the patient as having signs of TMD(Morawa et al. 1985; Ogura et al. 1985). These Discussion loose parameters were used intentionally to maximize This study developed and utilized an accurate and the sensitivity of associating wear faceting with TMD reliable format for TMDevaluation of the young child signs. Data were evaluated with Chi-square testing at a patient. All evaluation parameters were objective, re- 95%confidence limit. The Statistical Package for the Social Sciences was used for computer data analysis. producible, and involved no discomfort or lengthy pro- cedures for the child. Nilner and Lassing (1981), Nilner To maximizethe sensitivity of this study, any single (1986), and Cash (1988) showed that questioning chil- finding made the patient positive for signs of TMD.In

264 PEDIATRIC DENTISTRY: SEPTEMBER/OCTOBER , 1991 -- VOLUME 13, NUMBER 5 dren younger than age 7 is unreliable. Children are Major Goho was resident, Pediatric Dentistry, and Lieutenant Colo- unaware of parafunctional habits (Love and Clark 1978) nel Jones is deputy director, Pediatric Dentistry Residency, Ft. Lewis, WA. and the manner of asking questions often leads young children to a particular response (Riolo et al. 1988; AhmadR: Bruxism in children. J Pedod 10:105-26, 1986. Okeson 1989). Parental questioning about a child’s Bernal M, Tsamtsouris A: Signs and symptoms of temporomandibu- parafunctional habits or symptomsalso is unreliable lar joint dysfunction in 3 to 5 year old children. J Pedod10:127-40, 1986. (Cash 1988). Other inappropriate or uncomfortable di- Carlsson GE: Epidemiological studies of signs and symptoms of agnostic procedures for young children include TMJ -pain-dysfunction: a literature review. palpation with fingers in the auditory meatus, and Aust Prosthodont Soc Bulletin 14:7-12, 1984. intraoral palpation of the pterygoid muscles. The ex- Cash RG: Bruxism in children. Review of the literature. J Pedod 12:107-27, 1983. amination used in this study is realistic for a pediatric Droukas B, Lind6e C, Carlsson GE: Relationship between occlusal dental practice and still includes the major clinical signs factors and signs and symptoms of mandibular dysfunction. A associated with TMD. clinical study of 48 dental students. Acta Odontol Scand 42:277- The incidence of TMDassociated signs was low, 83, 1984. Dworkin S: Reliability of clinical measurements in temporomandibu- even though just one finding was sufficient to catego- lar disorders. Clin J Pain 4:89, 1988. rize a patient as positive for TMDsigns. Comparedto Egermark-Erikkson I, Carlsson GE, Ingervall B: Prevalence of man- other child studies, this study finds even lower inci- dibular dysfunction and orofacial parafunction in 7-, 11- and 15- dence of some TMDassociated signs (Table). This year old Swedish children. Eur J Orthod 3:163-72, 1981. Grosfeld O, Czarnecka B: Musculo-articular disorders of the probably due to the use of only objective, reproducible stomatognathic system in school children examined according to examination procedures that minimized false positive clinical criteria. J Oral Rehabil 4:193-200, 1977. results. All findings were mild, confirming Carlsson’s Hansson T, Nilner M: A study of the occurrence of symptoms of (1984) observation that children’s TMDsymptoms are diseases of the temporomandibular joint masticatory muscula- ture and related structures. J Oral Rehabil 2:313-24, 1975. seldom severe. Helkimo M: Studies on function and dysfunction of the masticatory Interrater reliability was good. However,most of the system II. Index for anamnestic and clinical dysiunction and subjects exhibited negative findings and the reliability occlusal states. Sven Tandlak Tidskr 67:101-19, 1974. testing often measured agreement in finding absence of Ingerval B: Variation of the range of movmentof the mandible in relation to facial morphology in young adults. Scand J Dent Res signs. To further validate interrater reliability either a 79:133-40, 1971. larger subsample size (N) or a select subsample with Keith DA: Etiology and diagnosis of temporomandibular pair and positive findings is needed. dysfunction: organic pathology (other than arthritis). The President’s Conference on the Examination, Diagnosis, and Man- Conclusions agement of Temporomandibular Disorders. Chicago: ADA,1983, pp 118-22. Even with evaluation parameters that maximized Kirveskari P, Alanen P, Jgmsa T: Association between any dental wear/TMDsign association, and pediatric craniomandibular disorders and occlusal interferences. J Prosthet specific examination procedures, there was no statisti- Dent 62:66-69, 1989. Lindquist B: Bruxism in children. Odontol Revy 22:413-23, 1971. cally significant association between primary tooth wear Love R, Clark G: Bruxismand : a critical review. J facets and TMD-associated West Soc Periodont 26:104-11, 1978. signs. This lack of association in young children parallels Table. Cross-study comparisonof TMDsign prevalence in children similar findings in studies of dental wear and TMJsigns in Study Patient At least Opening Opening TMJ TMJ Muscle adults (Droukas et al. 1984; age one sign deviation limitation noise pain pain Seligman et al. 1988). These Present study 3-6 15% 12% 0% 7% 0% 1% similar results in both pedi- (control and study atric and adult populations group data pooled) strongly suggest that dental Bernal and 3-5 21% 11%° 4% 5% 3% -- wear at any age is not reason Tsamtsouris 1986 to suspect other TMDsigns Ogura 1985 6-18 10% -- -- 9o/o* 2% -- or TMJ. Therefore, lengthy ~ * examination, diagnosis of Grosfeld and 6-8 56% 360/o 0% 10% 6% -- TMD,and TMDtreatment for Czarnecka 1977 young children cannot be jus- Egermark-Erikkson 7 30% 5% 1% 11% 6% 20% tified solely by the presence 1981 of wear faceting. ¯ Did not count patients with "asynchronousmovement". * No measurementparameters given. ¯ Stethoscopeused to detect noise, -- Parameternot evaluated.

PEDIATRICDENTISTRY: SEPTEMBER/OCTOBER, 1991 ~ VOLUME13, NUMBER5 265 Morawa AP, Loos PJ, Easton JW: Temporomandibular joint dysfunc- Ramfjord SP: Bruxism, a clinical and electromyographic study. J Am tion in children and adolescents: incidence, diagnosis, and treat- Dent Assoc 62:21-44, 1961. ment. Quintessence Int 16:771-77,1985. Reding GR; Rubright WC, ZimmermanSO: Incidence of bruxism. J Nickel JC, McLachlan KR, Smith DM: Eminence development of the Dent Res 45:1198-1204, 1966. postnatal human temporomandibular joint. J Dent Res 67:896- Riolo ML,Ten Have TR, Brandt D: Clinical validity of the relationship 902, 1988. between TMJsigns and symptoms in children and youth. ASDCJ Nielsen L, Melsen B, Terp S: Prevalence, interrelation, and severity of Dent Child 55:110-13, 1988. signs of dysfunction from masticatory system in 14-16-year-old Rosner B: Fundamentals of Biostatistics. 3rd ed. Boston: PWS-Kent, Danish children. CommunityDent Epidemiol 17:91-96, 1989. 1990. Nilner M: Functional disturbances and diseases of the stomatognathic Rugh J, Harlan J: Nocturnal bruxism and temporomandibular disor- system. A cross-sectional study. J Pedod 10:211-38, 1986. ders. Adv Neuro149:329-41, 1988. Nilner M, Lassing S-A: Prevalence of functional disturbances and Seligman DA, Pullinger AG, Solberg WK:The prevalence of dental diseases of the stomatognathic system in 7-14 year olds. Swed and its association with factors of age, gender, occlusion, Dent J 5:173-87, 1981. and TMJsymptomatology. J Dent Res 67:1323-33, 1988. Ogura T, Morinushi T, Ohno H, Sumi K, Hatada K: An epidemiologi- Vanderas AP: Prevalence of craniomandibular dysfunction in chil- cal study of TMJdysfunction syndrome in adolescents. J Pedod dren and adolescents: a review. Pediatr Dent 9:312-16, 1987. 10:22-35, 1985. Vanderas AP, Ranalli DN: Evaluation of craniomandibular dysfunc- Okeson JP: Temporomandibular disorders in children. Pediatr Dent tion in children 6 to 10 years of age with unilateral cleft or cleft 11:325-29, 1989. lip and : a clinical diagnostic adjunct. Commentary.Cleft Padamsee M, Ahlin JH, Ko C-M, Tsamtsouris A: Functional disorders Palate J 26:332-38, 1989. of the stomatognathic system: Part II, a review. J Pedod 10:1-21, 1985.

FDAto test, set standards for gloves

The Food and Drug Administration (FDA) approved test methods and minimum quality levels for the billions of rubberand plastic gloves wornby dentists andother health care workers. The new regulations, which became effective March12, 1991, standardize manufac- turer testing and define the maximumfailure rate for the test, according to an item in the March1991 issue of DentaIManagement.The FDAwill examine randomly selected samples for tears, holes, and any foreign matter embeddedin the gloves. Gloves also will be subjected to a water leak test, and maynot be sold for medical use if leaks are found in morethan 25 per 1,000 of surgeons’ gloves and 40 per 1,000 of patient examination gloves. The FDAsays that these limits can be reproduced in its field laboratories, thus providing a standardlevel of quality. Foreign glove manufacturersmay be placed on an import detention list if their gloves consistently fail to meet the new FDArequirements. Domestic gloves that do not meet requirementswill be seized, if necessary, to keep them off the market.

266 PEDIATRICDENTISTRY; SEPTEMI~ER/OCTOI~I~R , 1991 -- VOLUME13, NUMBER5