Severity of temporomandibular disorder assessed by dysfunctional and arthropatic indexes and headaches in TMJ patients

Ciancaglini R.*, Gherlone E**., Paleari M*., Frattini D*., Familiari S*., Barone A*., Radaelli G***
* Department of Biomedical and Technological Sciences, University of Milan, Section of Dentistry and Maxillo Facial Surgery, Legnano Hospital;
** Department of Oral Rehabilitation San Raffaele Hospital, Vita e Salute University, Milan;
*** Section of Medical Statistics, Department of Medicine, Surgery and Dentistry, San Paolo Hospital, University of Milan

Headache and temporomandibular disorder are common complaints in the general population, possibly associated on a pathophysiological and clinical basis.

To assess whether a relationship exists between severity of TMD and headaches, in a clinical sample of patients referred to a TMJ clinic.

160 adult patients (126 women and 34 men; mean age 39 y, range 18-77) consecutively admitted at the TMJ Orofacial Pain Clinic, Maxillo Facial Department, Legnano Hospital (Italy), 2002.

Temporomandibular disorder (TMD). Temporomandibular disorder was assessed in accordance with the EACD protocol. Two indexes were used to evaluate severity of TMD: the Clinical Helkimo Dysfunctional Index * and the Clinical Radiological Arthropatic Index (CRAI)**

*Helkimo Clinical dysfunctional Index A) Symptom: Impaired range of movement/mobility index Criteria: normal range of movement=0 / slightly impaired mobility=1 / severly impaired mobility=5 B) Symptom: impaired TMJ function Criteria: smooth movement without TMJ sounds and deviation on opening or closing movement < 2 mm =0 TMJ sounds in one or both joints and/or deviation > 2 mm on opening or closing movements = 1 Locking and/or luxation of the TM Joint = 5 C) Symptom: muscle pain Criteria: no tenderness to palpation in masticatory muscles = 0 / Tenderness to palpation in 1-3 palpation sites = 1 / Tenderness to palpation in 4 or more palpation sites = 5 D) Symptom: TMJ pain Criteria: no tenderness to paolpation= 0 / tenderness to palpation laterally = 1 / tenderness to palpation posteriorly = 5 E) Symptom: pain on movement of the mandible Criteria: no pain on movement = 0 / pain on 1 movement = 1 / pain on 2 or more movements = 5 G) Dysfunctional group 0-5 according to code H) Clinical dysfunction index D, according to code Sum A+B+C+D+E= Dysfunction Score (0-25) *Helkimo, M. (1974) Studies on function and dysfunction of the masticatory system II. Index for anamnestic and clinical dysfunction and occlusal state.

**C.R.A.I. Index)(signs and sympthoms / score) A) TMJ sounds <3 months = 0 / 3 to 6 months = 1 / > 6 months = 2 B) Patient’s referred pain: absent = 0 / present = 3 C) TMJ pain on palpation: absent = 0 / mild to moderate = 2 / severe = 3 D) Radiological signs of ostetoarthritis (OA): absent = 0 / deviation in form (DIF) = 3 / osteophytes(other OA signs) = 5 CRAI = A+B+C+D (score 0-13) **Ciancaglini R. et al.,(1987) Assessment of arthtopathy of TMJ by digital Phonoarthrometry. Journal of Craniomandubular disorders: Facial and Oral pain

Headache. Headaches were assessed and classified in accordance with the HIS criteria. The following groups were considered: tension type headache, migraine, and other types of headaches.

Fig. 1. types of headache

Association between severity of TMD and headaches was assessed by the Mann-Whitney U test.

Fig 2. Prevalence of headaches in the sample Fig. 3. Prevalence of types of headache

The mean score (SD, median) of severity of TMD was 5.3 (4.9, 4) (Helkimo Index), and 5.1 (2.8, 5) (CRAI).
The Clinical Helkimo Dysfunctional Index and CRAI were correlated (Pearson r=0,59, P<0,0001).
Headaches occurred in 40 (25.0%) patients. Prevalence was 27.8% in women and 14.7% in men (P=0.172, Fisher’s exact test)
Table. Severity of TMD for different types of headaches, according to Helkimo Index and CRAI

			Helkimo Index (score)				CRAI (score)l
			Mean	Median	25°-75°		Mean	Median	25°-75°
					centile	Pa					Pa
No headaches			5.2	3	2-6			4.8	5	3-6
Any headaches			5.8	5	2-7	0.245		5.9	5.5	3-8	0.094
Tension-type headache	8.3	7	3-10.5	0.034*	6.5	6	4.5-9	0.036*
Migraine		5.1	4.5	3-5	0.507			5.5	3-10	0.296
2 Other headaches		5.6	5.5	3-7.5	0.954			4	2-6	0.457
avs. patients who did not reported headaches. *=statistical significance.

In this study an association was found between the severity of TMD and occurrence of tension-type headache in adult patients referred to a TMJ clinic, both using the Clinical Dysfunctional Helkimo Index and a Clinical Radiological Arthropatic Index. No significant association of TMD was found for both methods with migraine or other types of headaches. Both clinical examination of TMJ and headaches would be desirable in clinical TMJ patients for accurately performing diagnosis and planning.

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