Accepted Manuscript Validation of clinical tests for patients with long-lasting painful temporomandibular disorders with anterior disc displacement without reduction Elisabeth Heggem Julsvoll, MSc, RPT, MT, Nina Køpke Vøllestad, PhD, Hilde Stendal Robinson, PhD, RPT, MT PII:

S1356-689X(15)00134-4

DOI:

10.1016/j.math.2015.06.005

Reference:

YMATH 1732

To appear in:

Manual Therapy

Received Date: 4 September 2014 Revised Date:

1 June 2015

Accepted Date: 12 June 2015

Please cite this article as: Julsvoll EH, Vøllestad NK, Robinson HS, Validation of clinical tests for patients with long-lasting painful temporomandibular disorders with anterior disc displacement without reduction, Manual Therapy (2015), doi: 10.1016/j.math.2015.06.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Validation of clinical tests for patients with long-lasting painful temporomandibular disorders with anterior disc displacement without reduction

Hilde Stendal Robinson PhD a, RPT, MT

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Elisabeth Heggem Julsvoll MSc a, b, *, RPT, MT, Nina Køpke Vøllestad PhD a,

Department of Health Sciences, Institute of Health and Society, University of Oslo, Norway

b

Current work-address: Hans & Olaf Fysioterapi, Oslo, Norway

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a

The work should be attributed to: Department of Health Sciences, Institute of Health and Society, University of Oslo, P.O. Box 1089, Blindern, N-0318 Oslo, Norway * Corresponding author. Tel.: + 47 95941262

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E-mail address: [email protected] (E.H. Julsvoll)

ACCEPTED MANUSCRIPT ABSTRACT _____________________________________________________________________ Objective: To evaluate the validity of single clinical tests and cluster of tests used to identify anterior disc displacement without reduction (ADDWOR).

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Methods: Treatment-seeking patients with temporomandibular pain and limited mouth-

opening were recruited among patients from health-professionals in the region of Oslo in 2012. Thirty-five persons, aged 18–70 years, with 58 symptomatic joints or pain in

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surrounding area were included. The examinations were performed by one experienced manual therapist. Magnetic resonance imaging (MRI) was used as reference standard.

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Sensitivity, specificity, false positive, false negative and likelihood-ratios (LRs) with 95% confidence intervals (CIs) were calculated for single and cluster of tests. ROC analysis were used to see how well pain provocation tests discriminated between positive and negative ADDWOR.

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Results: The main result is that a cluster of 7 clinical tests (5 positive) can be used to diagnose ADDWOR with an accuracy of 71%. The dental stick test is the best single test with equal sensitivity as the cluster, but with lower specificity.

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Conclusion: To reveal ADDWOR in patients with TMD, we recommend using the cluster of the dental stick test, the isometric test, the joint provocation test, the joint sound test, the

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deviation test, the laterotrusion test and joint mobility test. Practice and implications: The tests require no advanced equipment, they are easy to perform and suitable for use in clinical settings. MRI can be seen as more of a supplement to the clinical tests than a necessity to start a clinical intervention.

ACCEPTED MANUSCRIPT Keywords: Temporomandibular disorders - TMD Anterior disc displacement without reduction - ADDWOR Clinical tests

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Validity

ACCEPTED MANUSCRIPT 1. Introduction A total of 4 - 7 percent (75 % women) of the Norwegian population seeks treatment for their temporomandibular disorders (TMD) during lifetime (Helsedirektoratet, 2008). TMD is a

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collective term to describe disorders affecting the temporomandibular joints (TMJ), masticator muscles and associated structures, all that can cause common symptoms such as pain and limited mouth-opening (Okeson and de Kanter, 1996). TMD is divided into external and internal disorders (Laskin et al., 2006b). External disorders are of myofascial origin, while internal disorders are

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divided into internal derangements (ID) and degenerative conditions (Dworkin and LeResche,

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1992; de Leeuw, 2008). ID can cause joint sounds such as “click” and “crepitus”. TMD patients may have combinations of the different conditions, which is important to have in mind during the clinical examination.

Each TMJ has three axes of movements, which shift each time the condyle displaces (Bermejo-Fenoll, 2010). The movements of the mandible can be distinguished into a hinge-like

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rotation and an anterior glide/translation (Laskin et al., 2006a). An articular fibrous disc divides the joint into two distinct compartments. The inferior compartment allows for the rotation between

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the disc and the mandibular condyle, while the superior compartment allows for the translation between the disc and the temporal surface (Bermejo-Fenoll, 2010). Movements in the joint are

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opening and closing the mouth, protrusion, retrusion and laterotrusion to both sides (lateral shift or lateral excursion) (Laskin et al., 2006a; Bermejo-Fenoll, 2010). A disc derangement is defined as a displaced disc relative to the condyle and eminence

of the temporal bone (Laskin et al., 2006b). Twenty percent of the Norwegian TMD patients are reported to have a disc displacement, where nine of ten are women (Strøm 2013). Disc displacement can cause movement limitation and give problems with for instance chewing, mouth- opening, yawning, talking, smiling, singing and brushing teeth (LeResche et al., 1991). Since the retrodiscal tissue, which is richly innervated, has been stretched progressively due to the

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ACCEPTED MANUSCRIPT anterior disc displacement, an increasing deep stretch pain can be felt in the affected joint (Langendoen et al., 1997; Tanaka et al., 2004; Manfredini, 2010; Okeson and de Leeuw, 2011). The disc displacement can be distinguished into anterior, anteriomedial, medial, anteriolateral, lateral or posterior of the caput mandibulae, where anterior displacement is the most

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common (Larheim et al., 2001; Harrison et al., 2014). With regard to clinical diagnosis and treatment, two predominant stages of anterior disc displacement are distinguished. The conditions (Figure 1) are called anterior disc displacement with reduction (ADDWR) and anterior disc

focuses on ADDWOR with limited mouth-opening.

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displacement without reduction (ADDWOR) (Perez del Palomar and Doblare, 2007). This study

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Activities of the mandible involve movements in both TMJs simultaneously. Hence, a disorder in one joint will affect the other and vice versa. Bermejo-Fenoll and co-authors (2010) showed that each TMJ may be viewed as consisting of two joints because of the upper and lower compartments, which is unusual compared to all other joints in the human body. An ADDWOR

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may cause limited mouth-opening since the disc makes an obstruction and prevents normal anterior glide of the mandible (de Leeuw, 2008). Due to this reduced glide, one-sided ADDWOR may cause deviation towards the affected side (Laskin et al., 2006b). Bilateral ADDWOR may

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result in different movement patterns depending on whether the disc displacements affect the anterior glide in either one or both joints. This is important to remember when performing the

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clinical tests. The result of both joints blocked can be limited mouth-opening (de Leeuw, 2008). Magnetic resonance imaging (MRI) is currently the most accurate imaging modality for

identification of disc positions of the TMJ with diagnostic accuracy of 95% for sagittal and coronal images (Tasaki and Westesson, 1993). Studies have shown good reliability for MRI regarding disc displacements. Kappa value for disc displacement with reduction was 0.78. Furthermore, the agreement for detection of disc displacements without reductions had kappa value of 0.94 and 97% agreement (Ahmad et al., 2009). These results show that MRI is not

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ACCEPTED MANUSCRIPT revealing disc displacement 100%. MRI was chosen as the reference standard in the present study although interpreted with caution. A literature search concerning diagnostic validity of clinical tests in temporomandibular ID revealed a lack of high-quality studies (Chaput et al., 2012). Moreover, there are gaps in our

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knowledge about how well clinical tests or cluster of tests perform in identification of ADDWOR (Strøm 2013). The Diagnostic Criteria for TMD (DC/TMD) (Schiffman et al., 2014) recommends certain tests to identify ADDWOR, but does not include tests for joint loading and cluster of tests.

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In clinical practice, decisions are usually based on response to several tests. One might

hypothesize that a cluster of relevant tests might be better to discriminate between positive and

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negative ADDWOR than single tests. The objective of this study was to explore clinical tests ability to reveal ADDWOR in patients with painful TMD with limited opening. We included patients with pain on one (unilateral) or both (bilateral) sides. 2. Material and methods

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2.1 Design and participants

In this cross-sectional study, men and women between 18 and 70 years of age, having pain in one or both TMJ’s or surrounding areas and with limited mouth-opening ( 0, while no pain and discordant pain were coded “No”. Pain in the actual area on the examination day prior to the examination and the worst pain the participants ever had had in the area were

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ACCEPTED MANUSCRIPT measured by a visual analog scale (VAS). Positive ADDWOR on MRI was coded “Yes” and negative ADDWOR “No”. ROCanalysis was used to set cut-off for pain intensity triggered by the provocation tests. The area

between positive and negative ADDWOR.

3. Results

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under the curve (AUC) was calculated and used to evaluate the tests ability to discriminate

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Thirty-five participants, 31 (89%) women, with 58 symptomatic joints were included (23 bilateral and 12 unilateral, surprisingly; 29 right/29 left), mean age (SD) 44 (13) years. Table 1 presents the

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demographic data, pain intensity, functional disability and additional complaints. Median pain intensity (min-max) on the examination day was 38 (4-90) on VAS, while the worst pain ever in the TMJ area was 84 (33-99) on VAS. Mean (SD) unassisted mouth-opening on the examination day was 33 (5) millimeters. The main activity limitations reported on PSFS, were chewing hard

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food (91%) and yawning (87%).

MRI revealed ADDWOR in 15 of the 58 joints, 7 right-sided and 8 left-sided. Three participants with bilateral pain also had bilateral ADDWOR. ROC analysis showed that for most

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of the tests a cut-off for pain intensity of 3 on NPRS gave the highest area under the curve (AUC) (95% CI). The dental stick test, AUC = 0.75-0.77 (0.56, 0.96), was the best single test to

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discriminate between positive and negative ADDWOR with the highest sensitivity (71-86%), specificity (71-77%) and LR (2.97-3.09) (Table 2). Of the joint sound tests, “crepitus” on opening had the highest sensitivity (63-71%), specificity (76-77%) and LR (2.63-3.09). Other tests, not included in the final analysis, had either weak or moderate sensitivity or specificity. When comparing the result for the 23 participants having bilateral with the 12 participants having unilateral pain at inclusion, the sensitivity and specificity of the dental stick test, the joint provocation test and the joint sound test remain the same. For the deviation and the laterotrusion

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ACCEPTED MANUSCRIPT tests, the sensitivity and the specificity increased in participants with unilateral pain around or in the TMJ. The analyses of the cluster for the right TMJ (Table 3) reveal that 71.4 percent of those with a positive ADDWOR had five or more positive tests, while 81 percent of those without

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ADDWOR had three or less positive tests. Left sides results were similar (data not shown). With five or more tests positive, the sensitivity and specificity of the cluster were 0.71 and 0.91 respectively and the LR was close to 8 (Table 4). The cluster, AUC = 0.71 (0.50, 0.91), could

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discriminate between positive and negative ADDWOR with an accuracy of 71%.

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4. Discussion

The main result of this study is that clinical tests can, with high probability, confirm whether patients with long-lasting pain in the TMJ area and limited mouth-opening would be diagnosed as an ADDWOR by MRI. A cluster of clinical tests (five of seven) is better than single tests alone.

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The dental stick test is the best single test with equal sensitivity as the cluster, but with lower specificity. Sensitivity of 0.71 and specificity of 0.91 for the cluster seems sufficient for use in

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clinical practice to decide on conservative treatment alternatives, and is also close to the previous recommendations (Dworkin and LeResche, 1992). The new DC/TMD recommends an even higher

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sensitivity and specificity (0.80 and 0.97 respectively) for examination of disc displacement without reduction with limited mouth-opening using MRI as the reference standard (Schiffman et al., 2014). Limited mouth-opening and interference with ability to eat satisfy the DC/TMDdemands, but pain provocation tests such as the dental stick test and the isometric test being important in physiotherapy-examination, are only mentioned as adjunctive tests. Moreover, the DC/TMD seems to focus more on palpation-provocation-tests. Palpation-tests in other body areas, however, are considered as subjective with low reliability (Billis et al., 2003; Seffinger et al., 2004; Robinson et al., 2007). Previously Chaput et al. (2012) have suggested that a cluster of clinical

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ACCEPTED MANUSCRIPT tests might reveal ADDWOR, however with low probability. Our results show that when using a cluster, an ADDWOR can be ruled out with high probability. Furthermore, when none of the clinical tests are positive ADDWOR is possibly not present. The cluster in the present study has few false-negative cases, hence useful in clinical practice in choosing treatment to joints with

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positive ADDWOR. The advantage of this study is that the assessor set no diagnoses. We wanted to identify the test(s) and/or cluster with the best association to ADDWOR on MRI.

The risk of giving inadequate, damaging treatment is present if the cause of limited

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mouth-opening is unknown. One of the most important conditions to rule out in this perspective is the ADDWOR. We think that assessing mobilization techniques in anterior direction and

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stretching of the superior belly of the lateral pterygoid muscle should be avoided in such cases. Therefore, it is important to have diagnostic tools and methods with high specificity. The low sensitivity and specificity for some of the tests used in the present study can partly be explained by the synergetic movement of the two TMJs. This might affect the response

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on the deviation test and the laterotrusion test. However, the number of participants with unilateral pain is low. Future studies should aim at comparing the response of these tests on a larger cohort including both uni- and bilateral TMD and also include acute patients, to further explore these

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tests methodological characteristics. Furthermore, clinicians should be careful with the conclusion on these two tests alone because of the uncertainty when both sides are symptomatic.

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In clinical and research settings one should be aware that positive response on the joint

sound test “crepitus” might also be due to secondary arthrosis (Look et al., 2010; Harrison et al., 2014).

Due to the small number of studies on TMD, further comparisons of results are difficult. However, there are studies exploring methodological qualities of clinical tests for other joints/areas. Laslett and co-authors (2005) examined both single tests and clusters of tests for sacroiliac joints. In accordance with our results they concluded that cluster of tests (three of six)

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ACCEPTED MANUSCRIPT revealed the condition better than single tests. The optimum cluster in their study had sensitivity, specificity and AUC of 0.94, 0.78 and 0.84 respectively, comparable with our results. Like us, they also suggested that when all tests are negative, the condition of interest can be ruled out (Laslett et al., 2005).

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The validity of clinical tests can be influenced by three factors: the participants, the assessor and the clinical test itself (de Vet, 2011). The present study was planned in accordance with the present recommendations (Chaput et al., 2012); describing the patient population, blinded

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assessments for both the clinical tests and MRIs and a definition of the diagnostic test. All of which are important to avoid systematic error. Furthermore, all the clinical tests were standardized

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and performed by one experienced manual therapist, which might bias the results. A novice might end up with other results, but clinicians with interest for TMJ problems can easily perform the tests after some practice. The time between the clinical examination and the MRI examination is reported and within the recommendations (de Vet, 2011). By using both sagittal and coronal MRI

Chaput et al., 2012).

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views, we have ensured high accuracy of the reference standard (Schwaighofer et al., 1990;

The sample size can seem small for a methodological study and to allow generalization.

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However, due to the low prevalence of TMD, it is demanding to get large study samples. Furthermore 35 persons with 58 symptomatic joints can represent the patient group fairly well

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(Carter et al., 2011). Besides, the sample was recruited among patients from a large number of clinical practitioners to ensure a sufficient number of participants. It can, however, be seen as a possible weakness that only 26% of the study sample was diagnosed with a positive ADDWOR on MRI. We studied long-lasting TMD-patients with pain and limited mouth-opening. Hence, we cannot generalize to neither acute patients nor ADDWOR patients without pain and/or with normal mouth-opening.

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ACCEPTED MANUSCRIPT The quality of the MRI can be influenced by the equipment and the skill and the experience of the radiologist. The magnetic field strength and the procedure might influence the quality (Tasaki and Westesson, 1993). We used skilled radiologists at a prestigious radiology center to perform the MRIs. Moreover, to optimize the description of the MRIs, an experienced

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professor in maxillofacial radiology interpreted the images and communicated the results.

5. Conclusion

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To reveal ADDWOR in long-lasting TMD patients with limited mouth-opening, we recommend to

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use a cluster of seven tests (dental stick test, isometric test, joint provocation test, joint sound test, deviation test, laterotrusion test and joint mobility test) were five tests have to be positive. The tests require no advanced equipment, they are easy to perform and suitable in clinical settings to provide basis for therapists in choosing treatment techniques. The treatment can start earlier and reduce the time with pain. MRI is expensive, has long waiting-time for examination and can be

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seen as more supplemental to the clinical tests than a necessity to start a clinical intervention. Future studies should also include acute TMD patients, a larger sample size and ensure a sufficient

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number with unilateral TMD.

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ACCEPTED MANUSCRIPT References Ahmad, M., Hollender, L., Anderson, Q., Kartha, K., Ohrbach, R., Truelove, E.L., John, M.T. and Schiffman, E.L. (2009) Research diagnostic criteria for temporomandibular disorders (RDC/TMD): development of image analysis criteria and examiner reliability for image analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107, 844-860.

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Altman, D.G. (1991) Practical statistics for medical research. Chapman and Hall, London. Bermejo-Fenoll, A. (2010) Anatomy of the Temporomandibular Joint and Masticatory Muscles, Current concepts on temporomandibular disorders. Quintessence, London, pp. 3-21.

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Billis, E.V., Foster, N.E. and Wright, C.C. (2003) Reproducibility and repeatability: errors of three groups of physiotherapists in locating spinal levels by palpation. Man Ther 8, 223-232.

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Carter, R.E., Lubinsky, J. and Domholdt, E. (2011) Rehabilitation research. Elsevier Saunders, St. Louis, Miss. Chaput, E., Gross, A., Stewart, R., Nadeau, G. and Goldsmith, C.H. (2012) The Diagnostic Validity of Clinical Tests in Temporomandibular Internal Derangement: A Systematic Review and Meta-analysis. Physiotherapy Canada. Physiotherapie Canada 64, 116-134. de Leeuw, R. (2008) Internal derangements of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 20, 159-168, v.

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de Vet, H.C.W. (2011) Measurement in medicine: a practical guide. Cambridge University Press, Cambridge.

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Dworkin, S.F., LeResche, L., DeRouen, T. and Von Korff, M. (1990) Assessing clinical signs of temporomandibular disorders: reliability of clinical examiners. The Journal of prosthetic dentistry 63, 574-579.

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Dworkin, S.F. and LeResche, L. (1992) Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. Journal of craniomandibular disorders: facial & oral pain 6, 301-355. Harrison, A.L., Thorp, J.N. and Ritzline, P.D. (2014) A proposed diagnostic classification of patients with temporomandibular disorders: implications for physical therapists. The Journal of orthopaedic and sports physical therapy 44, 182-197. Langendoen, J., Muller, J. and Jull, G.A. (1997) Retrodiscal tissue of the temporomandibular joint: clinical anatomy and its role in diagnosis and treatment of arthropathies. Man Ther 2, 191-198. Larheim, T.A., Westesson, P. and Sano, T. (2001) Temporomandibular joint disk displacement: comparison in asymptomatic volunteers and patients. Radiology 218, 428-432.

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ACCEPTED MANUSCRIPT Laskin, D.M., Greene, C.S. and Hylander, W.L. (2006a) Functional Anatomy and Biomechanics of the Masticatory Apparatus, TMDs - An Evidence-Based Approach to Diagnosis and Treatment. Quintessence, pp. 3-34. Laskin, D.M., Greene, C.S. and Hylander, W.L. (2006b) Internal Derangements, TMDs - An Evidence-Based Approach to Diagnosis and Treatment. Quintessence, pp. 249-253.

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Laskin, D.M., Greene, C.S. and Hylander, W.L. (2006c) Masticatory Muscle Pain and Dysfunction, TMDs - An Evidence-Based Approach to Diagnosis and Treatment. Quintessence, pp. 255-270.

Laslett, M., Aprill, C.N., McDonald, B. and Young, S.B. (2005) Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 10, 207-218.

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LeResche, L., Dworkin, S.F., Sommers, E.E. and Truelove, E.L. (1991) An epidemiologic evaluation of two diagnostic classification schemes for temporomandibular disorders. The Journal of prosthetic dentistry 65, 131-137. Look, J.O., Schiffman, E.L., Truelove, E.L. and Ahmad, M. (2010) Reliability and validity of Axis I of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) with proposed revisions. Journal of oral rehabilitation 37, 744-759. Manfredini, D. (2010) Physical Therapy, Current concepts on temporomandibular disorders. Quintessence, pp. 327-337.

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Okeson, J.P. and de Kanter, R.J. (1996) Temporomandibular disorders in the medical practice. The Journal of family practice 43, 347-356. Okeson, J.P. and de Leeuw, R. (2011) Differential diagnosis of temporomandibular disorders and other orofacial pain disorders. Dental clinics of North America 55, 105-120.

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Orsini, M.G., Kuboki, T., Terada, S., Matsuka, Y., Yatani, H. and Yamashita, A. (1999) Clinical predictability of temporomandibular joint disc displacement. Journal of dental research 78, 650-660.

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Perez del Palomar, A. and Doblare, M. (2007) An accurate simulation model of anteriorly displaced TMJ discs with and without reduction. Medical engineering & physics 29, 216-226. Robinson, H.S., Brox, J.I., Robinson, R., Bjelland, E., Solem, S. and Telje, T. (2007) The reliability of selected motion- and pain provocation tests for the sacroiliac joint. Man Ther 12, 72-79. Schiffman, E., Fricton, J. R., Haley, D. P., Shapiro, B. L. (1990) The prevalence and treatment needs of subjects with temporomandibular disorders J Am Dent Assoc 120, 295-303 Schiffman, E., Ohrbach, R., Truelove, E., Look, J., Anderson, G., Goulet, J.P., List, T., Svensson, P., Gonzalez, Y., Lobbezoo, F., Michelotti, A., Brooks, S.L., Ceusters, W., Drangsholt, M., Ettlin, D., Gaul, C., Goldberg, L.J., Haythornthwaite, J.A., Hollender, L., Jensen, R., John, M.T., De Laat, A., de Leeuw, R., Maixner, W., van der Meulen, M., Murray, 12

ACCEPTED MANUSCRIPT G.M., Nixdorf, D.R., Palla, S., Petersson, A., Pionchon, P., Smith, B., Visscher, C.M., Zakrzewska, J. and Dworkin, S.F. (2014) 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 Groupdagger. Journal of oral & facial pain and headache 28, 6-27.

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Schwaighofer, B.W., Tanaka, T.T., Klein, M.V., Sartoris, D.J. and Resnick, D. (1990) MR imaging of the temporomandibular joint: a cadaver study of the value of coronal images. AJR. American journal of roentgenology 154, 1245-1249. Seffinger, M.A., Najm, W.I., Mishra, S.I., Adams, A., Dickerson, V.M., Murphy, L.S. and Reinsch, S. (2004) Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine 29, E413-425.

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Stratford P, G.C., Westaeay M, Binkley J (1995) Assesing Disability and Change on Individual patients: A Report of Patient Specific Measure. Phys. Ther. 47, 258 - 263.

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Strøm, B.K., Dahm KT, Kirkhei I (juni 2013) Diagnostikk av temporomandibulære tilstander, in: M, N. (Ed.), Rapport fra kunnskapssenteret nr 10 - 2013. Systematisk oversikt. Nasjonalt kunnskapssenter, Oslo. Tanaka, E., del Pozo, R., Tanaka, M., Asai, D., Hirose, M., Iwabe, T. and Tanne, K. (2004) Three-dimensional finite element analysis of human temporomandibular joint with and without disc displacement during jaw opening. Medical engineering & physics 26, 503-511.

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Tasaki, M.M. and Westesson, P.L. (1993) Temporomandibular joint: diagnostic accuracy with sagittal and coronal MR imaging. Radiology 186, 723-729.

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Tasaki, M.M., Westesson, P.L., Isberg, A.M., Ren, Y.F. and Tallents, R.H. (1996) Classification and prevalence of temporomandibular joint disk displacement in patients and symptom-free volunteers. American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics 109, 249-262.

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The Norwegian Directory for Health – Helsedirektoratet (2008). Report in Norwegian. (Treatment for patients with Temporomandibular dysfunction (TMD)). Behandlingstilbud til pasienter som har Temporomandibular dysfunksjon (TMD), Oslo.

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ACCEPTED MANUSCRIPT Figure 1. A schematic representation of the position of the TMJ disc in three different conditions: a healthy joint, anterior disc displacement with reduction (ADDWR) and anterior disc displacement without reduction (ADDWOR). Reproduced by kind permission of Elsevier from Perez del Palomar and Doblare, 2007. In the closed mouth position, the disc is in an

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anterior position relative to the condylar head for both ADDWOR and ADDWR. The disc reduces (goes back to the normal position) upon opening the mouth, when an ADDWR is present. A click sound may occur when the disc reduces (Schiffman et al., 1990). The disc

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does not go back to the normal position, when an ADDWOR is present.

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Figure 2. The dental stick test.

The participant bites on a dental stick placed between the participants molares. Pain pointed out in the ipsi- or the contralateral joint is concidered as a positive test, while no pain or pain evoked in the surrounding areas is concidered as a negative test.

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Figure 3. The isometric test.

Isometric resistance on laterotrusion contralaterally; the test is positive if isometric laterotrusion to the left gives pain in the right joint and vice versa.

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Figure 4. The joint provocation test.

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With the pinkie in the external ear canal of the participant, the examiner gives a pressure of maximum 2 kilos for 1-2 seconds. If pain is reported, the test is positive. Figure 5. The joint sound test. Joint sound is tested with a stethoscope on each side separately, while the participant performs the different active movements of the jaw. “Click” or “crepitus” sounds are registered. Figure 6. The deviation test. The participant opens the jaw and the examiner observes if the participants jaw is deviating to

ACCEPTED MANUSCRIPT one side during opening and if it stays deviated in the end of the opening movement (positive test) or not (negative test). Figure 7. The laterotrusion test.

millimeter is registered as a positive test. Figure 8. The joint mobility test.

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Laterotrusion to the opposite side of the affected joint is measured with a ruler. Movement ≤ 9

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The examiner palpate the caput mandibulae in the preauricular area while the participant performs the different active movements of the jaw. The test is positive if the examiner

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registers a reduced anterior glide in the joint being tested.

ACCEPTED MANUSCRIPT Table 1 Demographic data, pain intensity, functional disability and additional complaints

n = 35

Frequency (%)

Median

Min - Max

31 (89)

Age

44 (13)

Years of education

14 (3)

Jaw opening, millimeter

33.3 (4.6)

Duration of pain, years

10 (2)

9 – 25

20.2 – 39.4 1 – 40

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Pain at present, VAS

19 – 66

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Women

Mean (SD)

84

Worst pain, VAS

Chewing hard food

32 (91)

Yawning

31 (87)

Additional complaints 28 (80)

Headache

27 (77)

Vertigo

17 (49)

Tinnitus

13 (37)

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Neck pain

33 – 99

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Activity limitation

4 – 90

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n; number of persons SD; standard deviation

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Min; minimum Max; maximum

VAS; Visual Analog Scale. Pain at present and worst pain were measured by VAS with the questions; On a 100 millimeter scale where 0 represent absence of pain and 100 represent the worst thinkable pain: 1. How will you grade your pain in the jaw today? 2. How will you grade the worst pain you ever have had in the jaw?

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ACCEPTED MANUSCRIPT Table 2 Characteristics for the seven clinical tests used to reveal anterior disc displacement without reduction (ADDWOR) in 58 TMJs (29 on the right TMJ and 29 on the left TMJ)* Sensitivity

Specificity

False

False

positive

negative

Dental stick test a 0.71

0.77

0.50

0.11

Left

0.86

0.71

0.46

0.06

Right

0.57

0.68

0.64

Left

0.38

0.62

Right

1.0

0.27

Left

1.0

0.19

Joint sound test

d

0.71

Left

0.63

Deviation test e

Left

0.75 (0.56, 0.94)

1.78

0.64 (0.38, 0.91)

0.28

1.0

0.50 (0.27, 0.74)

0.69

0

1.36

0.60 (0.37, 0.82)

0.68

0

1.23

0.54 (0.33, 0.75)

0.50

0.11

3.09

0.76

0.50

0.16

2.63

0.57

0.77

0.56

0.15

2.48

0.63

0.71

0.55

0.17

2.17

0.71

0.59

0.64

0.13

1.73

0.38

0.52

0.77

0.31

0.79

0.86

0.64

0.57

0.07

2.39

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Right

2.97

0.77

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Right

0.77 (0.57, 0.96)

0.73

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Joint provocation test c

0.17

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Isometric test b

Laterotrusion test f Right Left

Joint mobility test g Right

2

AUC (95 % CI)

3.09

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Right

LR

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Clinical tests

ACCEPTED MANUSCRIPT Left

0.88

0.57

0.56

0.08

2.05

TMJ; Temporomandibular joint * ADDWOR: 3 bilateral, 4 right unilateral and 5 left unilateral a; Biting on a stick with the molars gives pain in the ipsi- or contralateral joint

c; Pain evoked by palpation of the retrodiscal tissue d; “Crepitus” sound while opening the mouth e; The jaw moves ipsilaterally while opening the mouth

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f; Reduced range of motion to the opposite side

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b; Isometric resistance on contralateral laterotrusion gives pain in the ipsilateral joint

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g; Palpation of the mobility of the TMJ

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ACCEPTED MANUSCRIPT Table 3 Distribution of the positive and negative responses on the clinical tests included in the cluster a Frequency ( % )

N = 29 (Right side)

N = 22

Positive ADDWOR N=7

2 (9)

0

1 or more positive tests

4 (18)

0

2 or more positive tests

6 (27)

0

3 or more positive tests

6 (27)

4 or more positive tests

2 (9)

5 or more positive tests

0

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None positive tests / Negative

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Negative ADDWOR

2 (28.6) 0

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2 (28.6)

6 or more positive tests 7 positive tests

1 (5)

1 (14.2)

1 (5)

2 (28.6)

a; Dental stick test + Isometric test + Joint provocation test + Joint sound test + Deviation test + Laterotrusion

TMJ; Temporomandibular joint

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test + Joint mobility test

MRI; Magnetic resonance imaging

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N; Number of joints

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ADDWOR; Anterior disc displacement without reduction

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ACCEPTED MANUSCRIPT Table 4 Characteristics of the cluster of the seven tests a divided into positive and negative MRI diagnosed ADDWOR for 29 right-sided TMJs Sensitivity

Specificity

False positive

False negative

LR

1 or more positive tests

1.0

0.09

0.74

0

1.1

2 or more positive tests

1.0

0.27

0.70

3 or more positive tests

1.0

0.55

0.59

4 or more positive tests

0.71

0.82

0.44

5 or more positive tests

0.71

0.91

0.29

6 or more positive tests

0.43

0.91

0.4

0.17

4.78

7 positive tests

0.29

0.95

0.33

0.19

5.8

1.37

0

2.22

0.1

3.94

0.09

7.89

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0

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N = 29 (Right side)

test + Joint mobility test TMJ; Temporomandibular joint

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a; Dental stick test + Isometric test + Joint provocation test + Joint sound test + Deviation test + Laterotrusion

MRI; Magnetic resonance imaging

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N; Number of joints

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ADDWOR; Anterior disc displacement without reduction

5

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Figure 1.

1

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Figure 2.

2

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Figure 3.

3

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Figure 4.

4

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Figure 5.

5

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Figure 6

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Figure 7.

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Figure 8.

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ACCEPTED MANUSCRIPT HIGHLIGHTS

1. A cluster of 7 clinical tests (5 positive) is suitable to reveal ADDWOR in TMD patients

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2. The cluster of tests has sensitivity of 71% and specificity of 91% 3. The dental stick test has equal sensitivity as the cluster, but lower specificity 4. The tests are easy to perform and suitable for use in clinical settings

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5. MRI; a supplement to clinical tests, not a necessity to start treatment

ACCEPTED MANUSCRIPT ACKNOWLEDGEMENT ________________________________________________________________________ Grant support was provided by the Norwegian Fund for Postgraduate Training in Physiotherapy and the Norwegian Physiotherapy Association, department of Oslo. Gratitude

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is expressed to the participants, Hans & Olaf Physiotherapy clinic, Institute of Health and Society, University of Oslo, professor in maxillo-facial radiology Tore Arne Larheim and PhD student Anna Karin Abrahamsson at Institute of Clinical Dentistry, maxillofacial and

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oral surgeon Helge Risheim and Unilabs-Bryn Radiology Center.

ACCEPTED MANUSCRIPT Appendix The descriptions of the clinical tests The positions used when examining the participant

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The sitting position The participant is sitting comfortably upright, with a horizontal gaze, on a height-adjusted bench with the feet resting on the floor. The hips have an open angle and the hands are resting

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on the thighs. The supine position

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The participant is lying supine on a bench with a small pillow supporting the neck. The forhead and the chin are in level i.e. similar to the position used during the MRI examination.

The dental descriptions

2.1: The left maxillar central incisor

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1.1: The right maxillar front tooth (central incisor) 3.1: The left mandibular central incisor

4.1: The right mandibular central incisor

Interincisal: Between the central incisors of the maxilla (1.1 and 2.1) and the central incisors

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of the mandible (3.1 and 4.1).

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Maximal intercuspal position (MICP): The jaw is closed and the teeth are fully touching.

Pain provocation

Pain is reported and registered as a familiar (concordant) pain or an unfamiliar (discordant) pain, and is graded on an 11- points numeric pain rating scale (NPRS).

ACCEPTED MANUSCRIPT The clinical tests Test 1. Maximum unassisted jaw opening Purpose: To measure the ability to open the mouth. Performance of the test: The participant is supine. A caliper or a ruler is placed interincisal

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as close to the midline of the central incisor as possible. The 2.1 and 3.1 are selected as the maxillar and the mandibular reference tooth respectively. The assymetri between the midlines of the mandible and maxillar incisors is taken into account. Millimeter jaw opening is

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measured and pain is reported. Measurements are rounded to the nearest millimeter. Any

into account when measured.

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vertical incisal overlap (as shown in the two pictures above to the right) or open bite is taken

Interpretation of the test: The mouth opening is limited when the interincisal measurement is less than 40 millimeters. The test is used for inclusion in the study. Test 2. The deviation test

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Purpose: To examine if the jaw deviates during mouth opening. Performance of the test: The participant is in the sitting position, and is asked to open the

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mouth. The examiner observes if the participants jaw is deviating to one side during opening and if it stays deviated in the end of the opening movement .

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Interpretation of the test: If the jaw deviates to the left, there might be a restriction in the left TMJ or a laxity in the right TMJ. If the jaw deviates to the right, there might be a restriction in the right TMJ or a laxity in the left TMJ. If the jaw moves straight and the jaw opening is limited, there might be a restriction in both TMJs. If the jaw deviates to one side during the movement and corrects back to the midline/central position at full opening, it might be due to a disc displacement with reduction in the ipsilateral joint. Test 3. The laterotrusion test (lateral excursion) Purpose: To examine the ability to move the mandible laterally.

ACCEPTED MANUSCRIPT Performance of the test: The participant is in the supine position. From the midline between the participant’s central maxilla incisors (2.1 and 1.1), the examiner draws a vertical line on a reference tooth (selected by the examiner) in the participant’s mandible. On right lateral excursion the patient is asked to move the mandible to the right and on left lateral excursion

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the patient is asked to move the mandible to the left.

Interpretation of the test: The left lateral and the right lateral excursions are measured and pain is reported and registered. A limited laterotrusion to either side is defined as ≤ 9

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millimeters.

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Test 4. The joint mobility test Purpose: To test the mobility of both caput mandibulae.

Performance of the test: The test is performed both with the participant in sitting and supine position. The examiner palpate the caput mandibulae in the participant´s preauricular area, while the participant performs the different active movements of the jaw (opening, closing,

each joint separately.

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protrusive, retrusive and lateral movements). The examiner register the condylar movement in

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Interpretation of the test: Reduced condylar movement, especially in the anterior direction, is interpreted as a reduced joint mobility in the joint being tested.

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Test 5. The joint sound test

Purpose: To reveal if there are sounds like a “click” or “crepitus” when the participant moves the jaw. Normally the movements should be silent. Performance of the test: The participant is in the supine position. The examiner is testing each joint separately with a stethoscope, while the participant performs the different active movements of the jaw (opening, closing, protrusive, retrusive and lateral movements). Each of the movements are repeated three times to hear if the sound dissapears or remains the same all three times. Prior to the movements the participant must bring the posterior teeth into the

ACCEPTED MANUSCRIPT maximal intercuspal position (MICP). Interpretation of the test: Any “Click” or “crepitus” sounds are registered. A “click” sound is a distinct noise, of brief and very limited duration, with a clear beginning and end. A “crepitus” sound is a noice that is more continuous than the “click” sound.

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Note: It is important to distinguise if the sound comes from the actual joint and not from the opposite one. To make this distinction, we have to listen with and without the stethoscope to identify the source of the sound. In addition it is important that the assessor palpates each

Test 6. The dental stick test

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movements. I.e. to actually “palpate” the sound.

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TMJ separately with one fingertip on the skin overlying the joint during the different

Purpose: To provoke pain from the intra- or the extra articular structures. Performance of the test: The participant is in the sitting position and bites on a dental stick placed between the participants molares (see picture above). The left and the right sides are

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tested separately. The participant points out pain location with a fingertip. Interpretation of the test: Pain located over the ipsi- or contralateral joint is concidered as a

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positive test for the intraarticular structures of the joint. No pain or pain evoked in the surrounding areas is concidered as a negative test for the intraarticular structures. (Pain

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pointed out by the patient in the surrounding areas can be consider as a positive test for the extraarticular structures such as the mastication muscles.) Pain location and intensity are registered.

Test 7. The isometric test

Purpose: To provoke pain from the intra- or the extra articular structures. Performance of the test: The participant is in the supine position. The examiner gives an isometric resistance on opening, closing, protrusion, retrusion and left and right laterotrusion. The participant is instructed to keep the position of the mandible while the examiner gives

ACCEPTED MANUSCRIPT graded resistance. An effort is made by the examiner to prevent movement of the joint. Pain is reported and registered. Interpretation of the test: Pain pointed out by the participant (using one fingertip) on the ipsi- or the contralateral joint is concidered as a positive test for the intraarticular structures,

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while no pain or pain evoked in the surrounding areas is concidered as a negative test for the intraarticular structures. (Pain pointed out by the participant in the surrounding areas can be consider as a positive test for the extraarticular structures such as the mastication muscles.)

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Test 8. The joint provocation test

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Purpose: To provoke pain from the retrodiscal structures.

Performance of the test: The participant is in the supine position. With the pinkie in the participant´s external ear canal, the examiner gives a pressure of maximum 2 kilos for 1-2 seconds to provoke pain from the retrodiscal structures.

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is reported and registered.

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Interpretation of the test: If pain is evoked, an intraarticular structure can be the cause. Pain

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The sitting position

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The supine position

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The dental descriptions

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Test 1 (3 pictures)

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Test 2 (two pictures)

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Test 3

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Test 4

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Test 5

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Test 6

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Test 7

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Test 8

Validation of clinical tests for patients with long-lasting painful temporomandibular disorders with anterior disc displacement without reduction.

To evaluate the validity of single clinical tests and cluster of tests used to identify anterior disc displacement without reduction (ADDWOR)...
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