Advances in Dental Research

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Temporomandibular Disorders: Assessment of Psychological Factors J.D. Rugh, B.J. Woods and L. Dahlström ADR 1993 7: 127 DOI: 10.1177/08959374930070020301 The online version of this article can be found at: http://adr.sagepub.com/content/7/2/127

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TEMPOROMANDIBULAR DISORDERS: ASSESSMENT OF PSYCHOLOGICAL FACTORS J.D. RUGH B.J. WOODS L. DAHLSTROM

University of Texas Health Science Center Department of Orthodontics 7703 Floyd Curl Drive San Antonio, Texas 78284-7910 Adv Dent Res 7(2): 127-136, August, 1993

Abstract—Factors such as psychological stress, anxiety, depression, oral habits, and chronic pain behaviors have been found in subgroups of Temporomandibular Disorders (TMD) patients. This paper reviews the current status of diagnostic methods and instruments designed to identify various psychological factors. The authors offer the following general conclusions: Although the DSM-III-R has significant limitations, it is currently the most common gold standard with which other psychological instruments are compared. There are several specific assessment instruments, such as the Beck Depression Inventory and the Zung Self-Rating Depression Scale, which have been found to have acceptable sensitivity and specificity scores. In addition, certain simple screening questions may be cost-effective for the identification of psychological factors. Because of studies indicating that the dentists1 recognition of psychological factors is inaccurate, a brief screening questionnaire may be useful in TMD patients. The literature does not support the routine use of the MMPI. A major conclusion of this review is that there are several psychological instruments available which have demonstrated reasonable validity through a blind comparison with a gold standard. There is need for further development and testing of brief screening instruments using clinical decision methods.

Presented at the 12th International Conference on Oral Biology (1COB), "Modern Concepts in the Diagnosis of Oral Disease1', held at Heriot-Watt University, Edinburgh, Scotland, July 6-7,1992, sponsored by the International Association for Dental Research and supported by Unilever Dental Research The preparation of this manuscript was supported in part by USPHS Research Grant DE-09630 from the National Institute of Dental Research, National Institutes of Health, Bethesda,MD 20892.

T

his paper first reviews the theoretical and clinical rationale for the assessment of psychological and behavioral factors in patients with Temporomandibular Disorders (TMD). The paper next discusses the current gold standard(s) for the identification of psychological and mental disorders. We next review a sample of studies which have examined the accuracy of various clinical interviews and psychological inventories using the measures of sensitivity, specificity, and positive and negative predictive value. We close with a summary and discussion of research needs.

RATIONALE FOR PSYCHOLOGICAL ASSESSMENTS The rationale for psychological assessments of patients with TMD is based upon the assumption that psychological factors may predispose, serve as etiological factors, and maintain or be a consequence of TM Disorders. Evidence has been accumulating since the 1950's that psychological factors are of concern in certain subgroups of patients with TM Disorders. Investigators using various psychological and behavioral assessments have reported finding depression, anxiety, oral habits, chronic pain, and compromised coping skills in a certain percentage of TMD patients (see reviews by Malow et aU 1981; Greene et ai, 1982; Rugh, 1983, 1987; Moss and Garrett, 1984; Eversole et aL, 1985; van der Laan et al., 1988a,b;Grzesiak, 1991; Rugh and Davis, 1992). Fricton era/. (1985) reported clinically significant anxiety in 26% of 164 MPD patients. Seventeen percent of TMD patients evaluated by Gerschman et al. (1987) were identified as having severe anxiety. Anxiety has been proposed as an etiological factor through oral habits and increased muscle tension. Anxiety may also be a result of pain, serving to lower pain thresholds and make patients less tolerant of pain (Melzack, 1986). Depression, which also lowers pain thresholds and decreases tolerance for pain, has been commonly reported. In a study of 368 TMD patients, Gerschman et aL (1987) found that 18% of the patients had severe depression. It is recognized that anxiety and/or depression may be an etiological factor in some cases (Harness and Rome, 1989); in other cases, however, anxiety or depression may result from a TM Disorder (Gale, 1978; Gamsa, 1990). Finally, in some cases, anxiety and/or depression may exist independently of the condition and may not be related. Clinically significant depression and/or anxiety is found in patient and non-patient populations with various frequencies. Moderate to severe depression, for example, is reported in about 6% of ambulatory medical patients (Nielsen and Williams, 1980). In each case, however, appropriate patient management requires that these conditions, when clinically significant, be recognized and managed. Other commonly reported psychological and behavioral etiological factors include oral habits (Laskin, 1969; Moss et al., 1984), stressful life events, and nocturnal bruxism (Rugh

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and Harlan, 1988). Brooke et al (1977) noted that 80% of 194 Myofascial Pain Dysfunction (MPD) patients reported destructive oral habits. High correlations have been reported between muscular pain symptoms and stressful life events (Duinkerkeeftf/., 1985;Lundeenefa/., 1987). Speculand etal. (1984) reported that TMD patients experience more than twice as many stressful life events as a control population. Stressful life events occurring within 6 months of the onset of the TMD condition were compared in 85 "TMJ dysfunction" patients and 85 control patients. Using the "brought forward times" technique, the authors estimated that approximately 50% of the TMJ dysfunction onsets were attributable to life events which played a role in onset. Events involved work, money, health, and loss of interpersonal relationships. Studies such as these lend support to the assumption that some TM Disorders are similar to musculoskeletal aches and pains occurring elsewhere in the body. They are frequently related to the behavior of the individual and may require identification of specific behavioral problems or life-style characteristics. Recently, there have been several efforts to compare psychological characteristics among subgroups of TMD patients who have different diagnostic classifications of TMD, i.e., muscle vs. joint problems (Eversole etal., 1985; Butterworth and Deardorff, 1987; McCreary et al, 1991). These studies generally find more psychological factors in patients with muscle-related conditions. These results provide further justification for the consideration of psychological assessments. An assessment of psychological factors is increasingly being included in clinical evaluations of TMD patients because it is now recognized that occlusal and other structural indicators,

alone, are insufficient to provide an adequate diagnosis and management strategy for many TMD patients. There is no consensus on the percentage of patients for whom psychological factors are important; however, the number appears to be sufficiently high that current guidelines for diagnosis and treatment of TMD (McNeill, 1990) recommend that each TMD patient be screened for psychological and behavioral factors.

GOLD STANDARD FOR PSYCHOLOGICAL AND BEHAVIORAL CONDITIONS Validation of a diagnostic instrument requires a blind comparison with a gold standard. Currently, the most commonly used gold standard for diagnosis of psychological conditions is the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R, 1987, 3rd revised edition). This document provides specific diagnostic criteria for virtually all mental disorders. Although it has specific limitations, this descriptive classification scheme is widely used in both research and clinical work. Its application is facilitated by the Structured Clinical Interview for DSMIII-R (SCID), which was published in 1990 (Spitzer et al, 1990). This document provides standardized interview procedures for making a diagnosis according to the criteria of the DSM-III-R. This publication includes diagnostic procedures for psychotic disorders (schizophrenia, psychosis, etc.), mood disorders such as depression and dysthymia, substance use disorders, anxiety disorders, somatoform disorders (somatization andhypochondriasis), eating disorders (anorexia and bulimia), and adjustment and personality disorders. It does not adequately address certain conditions

(1) Do you characterize yourself as depressed? Yes or No. If yes, rate severity:

1

2

4

3

mild

moderate

5 severe

(2) Do you characterize yourself as being anxious or tense? Yes or No. If yes, rate severity:

1 mild

2

3 moderate

4

5 severe

(3) Do you think you have experienced a lot of stressful situations over the past year ? Yes or No. If yes, rate severity:

1

2

3

mild

Question

*

1993

4

moderate

5 severe

Sen

Spec

PPV

Depression (Ques. 1)

72

83

74

82

40

Beck Depression Inventory

Trait Anxiety (Ques. 2)

83

47

51

81

40

STAI*

State Anxiety (Ques. 2)

82

41

37

84

30

STAI*

Life Stress (Ques. 3)

89

31

62

69

56

SRE*

NPV Base Rate

Gold Standard

STAI = State-Trait Anxiety Inventory; SRE = Schedule of Recent Experience.

Fig.— Self-assessment questionnaire for depression, anxiety, and stress. Sensitivity, specificity, and predictive values for each question are provided in the Table (adapted from Oakley et al., 1992). Downloaded from adr.sagepub.com by guest on July 13, 2011 For personal use only. No other uses without permission.

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related to chronic pain conditions such as illness behaviors, irrational beliefs about pain, and oral habits. An important feature of the DSM-III-R is the multiaxial diagnosis. This allows a disease or condition to be defined along several dimensions by the use of several separate evaluations. This multi-axial approach allows the patient's condition to be defined, for example, in terms of its etiology, the physical sequelae, and adaptive functioning. It is important to note that, as with all diagnostic schemes, the multi-axial DSM-III-R is influenced by the diagnostician' s ability and expertise. The objective in development of the DSM-III-R and SCID was to provide one agreed-upon gold standard for mental disorders which would take the place of the many diagnostic schemes and criteria which existed. Although reasonably well-accepted, it is not clear that the goal of having one diagnostic gold standard with widespread acceptance will be met. The difficulties appear to be both political as well as scientific; however, despite the problems, this diagnostic scheme appears to qualify as the most widely accepted gold standard for mental disorders. In addition, it is continuously being updated and revised to reflect newly acquired knowledge regarding the classification of psychological disorders. Two other classifications deserve mentioning. The International Association for the Study of Pain (IASP) has published a taxonomy of chronic pain conditions (Merskey, 1986). Also, recognizing multifactorial aspects of chronic pain, Turk and Rudy (1987,1988) have developed a Multiaxial Assessment of Pain (MAP). This classification system includes an assessment of physical, psychosocial, and behavioral aspects of a condition. The development of the MAP is based upon the observation that patients display a similar set of behavioral and psychological responses associated with chronic pain which is consistent despite different physical conditions, i.e., low back pain, headache, and TMD (Turk and Rudy, 1990). The MAP and I ASP classifications are relatively new. Their reliability, validity, and practicality are currently being studied. They have not been extensively studied by means of clinical decision methods with TMD patients. In summary, although there are limitations, at this time the gold standard most commonly referenced is the DSM-III-R and SCID.

Problem

129

TM PSYCHOLOGICAL ASSESSMENT

PSYCHOLOGICAL ASSESSMENTS OF TMD PATIENTS History and Interview The assessment of psychological factors is most often accomplished through a history and interview. Questions about life-style, behavioral patterns, and emotional condition are a common component of most clinical histories. The accuracy of identifying psychosocial problems from the clinical history has been the subject of considerable research in medicine. The research consistently finds that physicians tend to underrecognize psychological conditions (Knights and Folstein, 1977;Brody, 1980; Nielsen and Williams, 1980). For example, Nielsen and Williams (1980) reported that primary care physicians failed to identify about 50% of patients with depression. Brody (1980) reported that physicians failed to identify 76% of patients' stressful life events and 34% of psychiatric disturbances. When several different gold standards and populations are used, the conclusions are similar: Physicians generally under-recognize psychological conditions when taking a history. The implications are that the typical history and interview constitute an inadequate screening mechanism for psychological conditions.

Accuracy of Dentists' Assessments of Psychological Factors Since TMD patients most frequently are evaluated first by a dentist, there has been interest in assessing the accuracy of the dentist's ability to identify psychological factors from the history and interview. Oakley et al. (1989) compared the judgment of dentists' clinical impressions of the presence or absence of psychological problems in 107 TMD patients with standardized psychological tests. The standardized tests served as the gold standard. The results (Table 1) suggest that the dentists' impressions from the initial patient interview do not adequately identify psychological problems. Although sensitivity was acceptable on most scales, the specificity ranged from 19 to 58. The sensitivity of a diagnostic instrument is a measure of the instrument's ability to identify positive cases when they are known to be positive. The specificity is a measure of the instrument's ability to identify negative cases which are known to be negative. Both measures provide scores

TABLE 1 DENTISTS' ASSESSMENTS OF PSYCHOLOGICAL PROBLEMS* iSensitivity Specificity PPV NPV Base Rate Gold Standard

Trait Anxiety

80

19

36

63

38%

STAI/Trait Anxiety

State Anxiety

88

21

26

85

24%

STAI/State Anxiety

Life Stress

84

27

56

60

53%

Sched Recent Experience

Depression

74

56

40

85

28%


Defensive/Denial

53

58

40

71

34%

MMPI K Scale

From Oakley et al. (1989). Positive and negative predictive values are based upon the prevalence of positive findings with use of the various gold standards. Downloaded from adr.sagepub.com by guest on July 13, 2011 For personal use only. No other uses without permission.

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which range from 0 to 1, with 1 being a perfect score. A detailed discussion of these concepts is provided elsewhere in this volume and in other sources (Weinstein and Fineberg, 1980). In contrast to the studies reported above on physicians who tend to under-identify psychological conditions, the study by Oakley et al. (1989) found that the dentist over-identifies psychological problems, at least in a group of TMD patients. It is important to note that the dentists involved in the Oakley et al. study were very experienced clinicians whose primary interest was TMD. It is not clear that these results can be generalized to less experienced clinicians. It may be argued that dentists over-identify psychological problems if the patient is unsuccessfully treated. This needs further exploration. In any case, the results of studies with both the physicians and dentists suggest the need for a screening instrument to supplement the clinical opinion based upon a history and interview.

Questionnaires and Inventories Since the variability and problems in history-taking have been recognized, a great deal of effort has been given to the development of standardized questionnaires called "inventories" or "instruments". Sophisticated psychometric methods exist to develop, validate, and test the accuracy of inventories which can be used for the assessment of psychological factors. A detailed and widely accepted set of standards exists for the development of educational and psychological assessment instruments (American Educational Research Association etal., 1985). Most of the current widely used psychological inventories are developed and tested with use of these standards. In the next few sections, we briefly review several inventories which have been evaluated by the use of clinical decision methods. The inventories are most commonly compared with the DSM-III-R.

The MMPI The most widely studied psychodiagnostic inventory is the Minnesota Multiphasic Personality Inventory (MMPI). Several MMPI profile configurations identify personality trait patterns that have been associated with chronic pain, e.g., the "neurotic triad" and the "conversion V", lack of self-confidence, strange bodily sensations, denial of anger, and aggressiveness (Franz

et al, 1986). Depression is found to be highly correlated with various types of chronic pain, including TMD, and assessment of depression is a key component of many TMD psychological evaluations. The accuracy of the MMPI in identifying depression has been assessed by means of clinical decision methods. Turner and Romano (1984) assessed depression in 40 chronic pain patients using the MMPI (including two sub-scales for "subtle" and "obvious" depression). They also tested the Beck Depression Inventory (Beck etal., 1961; Beck and Beamesderfer, 1974) and the Zung Self-Rating Depression Scale. The DSM-III diagnostic criteria were used as the gold standard. Sensitivity and specificity were determined and used to compare the questionnaires (Table 2). The Zung Self-Rating Depression Scale and both forms of the Beck Inventory were superior to the MMPI; sub-scales of the MMPI were poorest of all. The authors point out that sensitivity and specificity co-vary with changes in the decision cut-off point for each of the measures. They further analyze some of the inherent limitations of the MMPI for prediction of treatment outcome, including the large number of sub-scales and the various statistical problems presented by the instrument. Although a historically popular instrument, the MMPI has not received strong support in recent years. Shorter, simpler instruments, such as the Beck Depression Inventory, are more frequently used and generally compare better with the currently accepted gold standard. In addition, patient compliance is likely to be much better when the shorter instruments are used. For these reasons, it is recommended that the shorter specific scales be used rather than the MMPI.

Screening for Personality Disorders Personality disorders—such as paranoia, antisocial, dependent, and obsessive-compulsive—have been assessed by means of a 152-item self-administered questionnaire entitled "The Personality Diagnostic Questionnaire-Revised (PDQ-R)" (HylerandRieder, 19$l;Hy\er etal., 1988). This instrument was designed to provide personality diagnoses consistent with the DSM-III-R. Hy ler et al. (1992) recently used clinical decision methodology to assess the validity of the questionnaire in a group of 59 applicants for psychoanalysis. The gold standard was two psychiatrist interviews—one using the

TABLE 2 SELF-REPORT ASSESSMENTS OF DEPRESSION* PPV Sensitivity Specificity NPV

Instrument Zung

1993

83

81

52

95

Standard Form

83

82

54

95

Short Form

83

89

65

95

75

75

43

92

17

86

23

80

Gold Standard DSM-III (2 raters)


MMPI Subtle Obvious

*

75 57 30 90 From Turner and Romano (1984). The positive and negative predictive values were calculated on an assumed depression rate of 20%. Downloaded from adr.sagepub.com by guest on July 13, 2011 For personal use only. No other uses without permission.

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Instrument

* t

131


TABLE 3 SELF-REPORT ASSESSMENTS FOR PSYCHOLOGICAL SCREENING Sensitivity Specificity PPV NPV Reference

Gold Standard

General Health Questionnaire* (28-item)

57

83

67

76

Benjamin etal, 1991

DSM-III-R Clin Interview Sched Goldberg etal., 1970

General Health Questionnaire (60-item)

69

75

77

66

Ross and Glaser, 1989

NIMH Diagnostic Interview Sched

General Health Questionnaire (28-item)

77

75

67

—

Morris and Goldberg, 1989

Psychiatric Interview

Hospital Anxiety and Depression Scale1^

75

74

—

—

Hopwoodef a/., 1991

DSM-III-R Clinical Interview Sched

Rotterdam Symptom Checklist1

75

79

—

—

Hopwood et al.y 1991

DSM-III-R Clinical Interview Sched

General screening for somatic symptoms, anxiety, social dysfunction, and depression (Goldberg and Williams, 1988). Screening for affective disorders.

Structured Clinical Interview (SCID-II) for the DSM-III-R, and the other using the Personality Disorders Examination (PDE). Sensitivities for the PDQ-R were all 80 or better for the majority of scales. Specificities ranged from 60 to 90. The investigators conclude that the PDQ-R may be used to screen for personality disorders in an outpatient and inpatient psychiatric setting. However, because of the high falsepositive rate, they recommend that positive diagnosis be verified by a clinician-administered interview. They argue that the PDQ-R is cost-effective, since fewer patients would need a complete evaluation.

setting—high enough to reduce the more costly clinical interviewing, low enough to ensure the identification of patients whose psychiatric problems will significantly interfere with treatment. There is need for improved screening instruments. The relatively low sensitivity and specificity values for the three different assessments provided in Table 3 indicate that these screening instruments would need to be used with a clear understanding of their limitations. It is also noted that these instruments have not been validated on TMD patients.

Screening for Depression and Anxiety

The TMJ Scale, a 97-item questionnaire, was developed specifically for the evaluation of "TMJ disorders" (Lundeen et al., 1986; Levitt etal, 1988). It assesses 10 factors believed to be relevant to TMJ. The instrument includes two scales, "psychological factors" and "stress", which are designed to screen for "abnormal psychological functioning" and the "patient's level of stress, both chronic and recent" (Levitt, 1990). This review deals only with these two scales. Cut-off scores on these two scales were set to identify patients with clinically significant psychological problems. The utility of these scales has been determined in a series of studies that used clinical decision methods (Levitt et al, 1987, 1988; Levitt, 1990). Data related to this analysis are presented in Table 4. The sensitivity and specificity values for these tests are comparable with those of other brief screening instruments (Table 3). All of these instruments have marginal values; however, each could be used with appropriate screening. Of concern with all these instruments is the high number of falsepositives which would result if they were used for screening where the prevalence of a condition is low. It is also noted that the TMJ Scale was not tested against the DSM-III-R but rather the SCL-90 and the Derogatis Stress Profile. While both of

Psychological assessments have been designed for the general screening of psychological conditions. The General Health Questionnaire (GHQ) (Goldberg and Williams, 1988) is an easily administered paper-and-pencil test for first-line screening of psychiatric illness, including somatization, anxiety, social dysfunction, and depression. It is designed to be followed by a structured clinical interview as a secondary screening for those patients scoring above a set cut-off. Benjamin et al. (1991) have examined its use in a pain clinic setting in comparison with the clinical interview gold standard (Goldberg's "Clinical Interview Schedule", Goldberg et al, 1970). The results of this study and of others testing similar instruments are presented in Table 3. The authors point out that "changes in threshold have little effect on negative predictive value, but higher thresholds result in lower misclassification rates and higher positive predictive values. The choice of vbest' cutting score depends on the way in which the screening test is to be used". For early screening purposes, in a clinical setting, these authors conclude that the positive predictive value (PPV) of a screening test is the most important. Thus, they recommend setting the threshold at the most cost-effective point for each

Assessments Designed Specifically for TMD Patients


132

ADV DENT RES AUGUST

RUGH ET AL.

1993

TABLE 4 TMJ SCALE ASSESSMENTS OF PSYCHOLOGICAL FACTORS Sensitivity Specificity Gold Standard Reference

Instrument TMJ Scale Psychological Factors

76

74

Levitts ai, 1987

SCL-90 (GSI)

Stress

74

71

Levitt et al, 1987

Derogatis Stress Profile (TSS)

these instruments are considered valid, a comparison with the DSM-III-R would provide a stronger case. It is commendable that the developers of the TMJ Scale accomplished the many studies which assess the efficacy of the instrument. Another instrument developed for the assessment of behavioral and psychological factors in TMD patients, IMPATH (Fricton et al., 1987), to our knowledge has not been evaluated by means of the decision model.

psychological factors. They suggest that a positive finding on the screening questions should be followed up with more lengthy psychological tests which, if positive, would then be followed by a psychological interview conducted by a qualified professional. It is our opinion that this approach is the most clinically reasonable and cost-effective approach to assessment of psychological factors in TMD patients at this time.

A Simplified Approach

For some disorders, measurable physiological parameters exist which may be used in the diagnostic process. Since many conditions are believed to involve the muscle, psychophysiological assessments for TMD have involved measurement of postural and stress-related jaw muscle activity (EMG). This area has been very controversial because of advertising claims by manufacturers and the premature enthusiasm of some investigators. The initial enthusiasm was based upon studies which found differences in masseter and/or temporalis muscle activity between patients with and without TMD (Rugh and Montgomery, 1987; Katz et a/., 1989; Rudy, 1990; ¥\oretal, 1991; Schroeder et al, 1991). Two studies have used clinical decision methodology and have provided figures on sensitivity and specificity. These studies are presented in Table 5. In general, the EMG assessments have unacceptably low sensitivity scores, which result in a very high percent of false-positives. The high specificity and positive predictive value reported for the left temporalis in Table 5 (first line) are misleading. They are the result of a small sample size and would be statistically unlikely

The complex and lengthy psychological inventories which are frequently used for psychological evaluation may not be necessary for initial screening of TMD patients. Gale and Dixon (1989) reported that two simple questions correlate very well with the more lengthy questionnaires. The two questions were: "How depressed are you?" and "Do you consider yourself more tense than calm or more calm than tense?" Unfortunately, Gale and Dixon did not analyze their data using clinical decision methodology. The recent study by Oakley et al. (1993) used a similar set of simple questions and a VAS Scale to screen for anxiety, depression, and stressful life events (Fig.) in 116 TMD patients. They compared the patient responses to these questions with the results obtained with the Beck Depression Inventory, the State Trait Anxiety Inventory, and the Schedule of Recent Experience. The Fig. provides the sensitivity, specificity, and predictive values for a cut-off value designed to minimize false-negatives (high sensitivity). Oakley and colleagues conclude that the selfreport questionnaire may be useful in screening for

Physiological Assessments

TABLE 5 ELECTROMYOGRAPHIC ASSESSMENT OF MPD/TMD PATIENTS* Electrode Placement

Sen.

Spec.

PPV

NPV

Lf Temporalis

40

100

100

94

Rt Temporalis

15

95

25

90

Lf Masseter

40

95

47

93

Rt Masseter

25

95

36

92

Lf Temporalis

20

95

31

91

Rt Temporalis

10

90

10

90

Lf Masseter

15

95

25

91

Cut-off

Gold Standard

Reference

2SD>X

DDS Clinical Exam

Glarose/a/., 1989

2SD>X

DDS Clinical Exam

Rugh and Davis, 1990

Rt Masseter 05 95 01 90 Resting EMG values were used in both studies. The cut-off for both studies was set at 2 SD above the mean for non-patients. Predictive values were based upon a 10% base. Downloaded from adr.sagepub.com by guest on July 13, 2011 For personal use only. No other uses without permission.

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because the cut-off point was set two standard deviations above the mean for healthy patients. One would project 2.5% false-positives with a normal distribution and a larger sample. With the small sample (N = 20) used in this study, no healthy patients happened to have scores two standard deviations above the mean which resulted in a misleading high-positive predictive value. A major problem with electromyographic evaluation is that the laboratory setting in which the assessments have been made has not been validated; i.e., it is not clear that the patient' s response in the laboratory setting is predictive of the response in the natural environment. Second, the relatively small differences in levels of EMG have not been correlated with the site of muscle pain. Finally, it is unlikely that 1 or 2 |LIV in muscle activity, which is commonly found, would result in muscular pain. The consensus at this time is that laboratory EMG assessments have not been shown to be valid diagnostic aids for TMD (Laskin and Greene, 1990; Mohl et ai, 1990; Rudy, 1990). Electromyography has also been used to monitor nocturnal bruxism and diurnal oral habits, both of which are believed to be etiological or contributing factors in a subgroup of TMD patients (Rugh and Harlan, 1988). Issues related to assessment of nocturnal bruxism are beyond the scope of this review.

PREDICTING TREATMENT OUTCOME Several studies have attempted to predict treatment outcome through pretreatment psychological questionnaires and inventories. Unfortunately, they have not been administered to TMD patients by means of clinical decision methods. Turner et al. (1986) attempted to predict the outcome of 106 patients receiving lumbar surgery, utilizing the 1979 Smith and Duerksen Pain Assessment Inventory (PAI). This scale is a combination of weighted MMPI scales for predicting post-surgical pain. Surgical outcome and return to work at one-year follow-up were set as criteria measures of outcome (gold standard). Good vs. fair or poor surgical outcome was correctly predicted in 79% of the patients studied by the Pain Assessment Index. However, problems were identified by the examination of sensitivity and specificity (Table 6). Sensitivity was only 33% for the prediction of "fair" or "poor" responders. Based on conclusions from additional statistical data and examination of variance achievable by

lowering the cut-off score, the recommendation was made by these authors for clinicians to develop their own cut-off levels for their particular setting. These authors further report, however, that the Hypochondriasis Scale (Scale 1) of the MMPI, when used alone, proved to be a better indicator of surgical outcome (see Table 6). The authors conclude that integration of PAI or HS Scale test results with other clinical data would tend to be the best choice for the clinician. It would be valuable to determine if this assessment would be useful to predict outcome of TMD treatment. Gerke and colleagues (1989) recently used discriminant function analysis to assess a number of psychological, illness behavior, and clinical variables to predict outcome of TMD patients to conservative therapy. They evaluated the Helkimo Index, the Illness Behavior Questionnaire (IBQ), the Spielberg State-Trait Anxiety Inventory, the Zung Depression Test, Life Events Questionnaire, a muscle and TMJ index, an occlusal (teeth) index, and a radiographic index of joint pathologies. Discriminant functions were calculated for various combinations of 20 variables against the 43 patients' views of treatment outcome. Although sensitivity and specificity figures were not provided, the percentage of correctly classified patients was provided. The investigation reported that none of the assessments, when used alone, was particularly useful; however, when psychological and clinical examinations were used in combination, the percentage of correct predictions was over 80%. It would be useful for these interesting data to be re-analyzed in terms of the clinical decision methods. Although the number of subjects was small, this research report is important, since it documents the feasibility and value of combining discriminant function analysis and clinical decision methods. Tversky et al. (1991) recently evaluated the Hamilton Rating Scale for Depression as an outcome predictor of splint and antidepressant therapy. Unfortunately, data were not provided to allow for the calculation of sensitivity and specificity.

DISCUSSION Psychological factors including anxiety and depression, lifestyles, stress-related biochemical and muscular responses, family relations, and habits have been recognized as factors in many medical and dental disorders. The emergence and dramatic

TABLE 6 PREDICTING TREATMENT OUTCOME* Instrument

Treatment

Sensitivity

Specificity

Pain Assessment Index

33

95

Hypochondriasis

63

90

Pain Assessment Index

47

95

63

85

MMPI

*

Hypochondriasis From Turner et al (1986).

Gold Standard

Current Classif.

Back Surgery Treatment Outcome

79 83

Return to Work


87 81

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growth of the fields of psychosomatic medicine and, more recently, behavioral medicine provide recognition of the role of psychological factors in both the etiology and management of human diseases and conditions. A major thrust of these fields is the identification of psychological aspects of various conditions such that logical and clinically effective treatment strategies can be provided. Although several sophisticated methods are commonly used to describe the accuracy of psychological assessments, the clinical decision methodology has not been commonly used. The recent review of behavioral assessment of chronic orofacial pain (Keefe and Beckham, 1990), for example, does not mention clinical decision methods. There are some clear advantages in an analysis of diagnostic instruments for psychological factors using clinical decision methods. This methodology helps organize the research efforts and provides information regarding the accuracy of the test in a manner which is relatively easy to understand by the dentist in practice. This methodology is commonly used in medicine and is being used with increasing frequency in dentistry. It is a valuable tool which, because of its simplicity, may help bridge the communication gap between the investigator and clinician. Although clinical decision methodology is being used with increasing frequency, the more sophisticated aspects, such as Receiver Operating Curves (ROC's), are seldom used. In addition, there has been little discussion of the adequacy of the various gold standards. Also lacking in current studies is discussion regarding the adequacy of test populations. Most test populations are poorly defined and do not provide an appropriate spectrum of patients. Several studies compare patients with significant disease with patients without disease; however, these distinctions are often easily made through a history. The need is for diagnostic instruments which can distinguish between patients who have different but commonly confused pathologies such as ear problems vs. TMD problems. There has been very little effort in this regard. A major conclusion of this review is that several of the psychological evaluations examined have demonstrated validity through a blind comparison with a gold standard. Most instruments have marginally acceptable sensitivity and specificity, however, and they must be used with considerable caution, particularly when the prevalence of the condition deviates much from 50%. Acceptable positive and negative predictive values can be achieved if the examiner's pretesting assessment and screening for psychological factors are fairly accurate. There is clearly room for improvement in the accuracy of the instruments; however, the instruments available are useful. Most of the instruments reviewed have been validated on patients with a variety of physical complaints, but not on TMD populations. Psychological assessment instruments have generally shown reasonable consistency when applied to populations with diverse physical complaints. Thus, it is anticipated that the efficacy of these instruments would hold when applied to TMD patients; however, this must be tested. A major problem in the literature is the lack of a diagnostic classification scheme for oral habits. There is need for the

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development of specific criteria based upon measurable parameters for oral habits, such as tongue thrust swallow, diurnal bruxism, nocturnal teeth grinding, and lip, tongue, and cheek biting. The classification initially may be behaviorally based. The relation of most oral habits to oral pathologies and conditions has not been determined. Once classification schemes are developed, they may be tested by means of clinical decision methodology. In summary, the use of clinical decision methods as a model for the evaluation of the adequacy of psychological assessments of patients with TMD is a relatively new effort. Studies accomplished thus far suggest that this methodology will provide a valuable approach to the identification of valid assessment instruments and clarification of the problems in this area.

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