Reduced Neuropsychologic Measures as Predictors of Treatment Outcome in Patients with Temporomandibular Disorders

Aims: To determine via a prospective investigation whether the presence of neuropsychologic or cognitive deficiencies could be identified in patients with temporomandibular disorders (TMD) and used to predict treatment outcome. This was based on the theory that measurable reductions in neuropsychologic and cognitive function might have a negative impact on treatment outcome in patients with essentially nontraumatic TMD, as has been shown for patients with posttraumatic TMD. Methods: Various neuropsychologic, psychosocial, and clinical parameters (including but not limited to the Peterson-Peterson Consonant Trigram Test and the California Verbal Learning Test) were used to pretest patients suffering from TMD prior to treatment. Patients were then entered into treatment, after which determination of treatment success was made both by the use of visual analog scales for pain and global transitional outcome measures (eg, “better,” responders versus “same/worse,” nonresponders). After determination of treatment success was made, treatment response was correlated with the various clinical, cognitive, and neuropsychologic test scores. Results: Overall, the nonresponders did worse in both the neuropsychologic and psychosocial assessments, with greater memory deficits, sleep disturbances, depression, and fatigue and lower energy levels as compared to responders. Among the best predictors of treatment outcome were the Peterson-Peterson Consonant Trigram Test scores, as well as the scores on the California Verbal Learning Test (ie, poorer test outcomes predicted nonresponse). Neither responders nor nonresponders could be distinguished from one another based on clinical parameters of maximum interincisal opening or muscle tenderness. Three psychosocial variables were also found to be predictors of poor outcome: sleep disturbance, fatigue, and income. Pretreatment pain on chewing was also found to be a reliable predictor of poor treatment outcome. Conclusion: We conclude that various neuropsychologic, psychosocial, and some clinical parameters may provide pretreatment prediction of treatment outcome in an idiopathic TMD population.

temporomandibular disorders; psychological tests; treatment outcome; cognition; prospective study

1. Bell WE. Orofacial Pain: Classification, Diagnosis, Management, ed 4. Chicago: Year Book Medical Publishers, 1989.

2. Bonica JJ. Chapter 5. In: Bonica JJ, Liebeskind JC, Albe-Fessard DG (eds). Advances in Pain Research and Therapy. Vol 3: Proceedings of the Second World Congress on Pain, Montréal, Québec, 1978. New York: Raven Press, 1979.

3. Bonica JJ. Chapter 6. In: Bonica JJ, Liebeskind JC, Albe-Fessard DG (eds). Advances in Pain Research and Therapy. Vol 3: Proceedings of the Second World Congress on Pain, Montréal, Québec, 1978. New York: Raven Press, 1973.

4. Bonica JJ. Chapter 7. In: Bonica JJ, Liebeskind JC, Albe-Fessard DG (eds). Advances in Pain Research and Therapy. Vol 3: Proceedings of the Second World Congress on Pain, Montréal, Québec, 1978. New York: Raven Press, 1973.

5. Greene CS, Laskin DM. Long-term evaluation of treatment of myofascial pain dysfunction syndrome: A comparative analysis. J Am Dent Assoc 1983;107:235–238.

6. Kolbinson DA, Epstein JB, Senthilselvan A, Burgess JA. A comparison of TMD patients with or without prior motor vehicle accident involvement: Treatment and outcomes. J Orofac Pain 1997;11:337–345.

7. Vallon D, Nilner M, Soderfeldt B. Treatment outcome in patients with craniomandibular disorders of muscular origin: A 7-year follow-up. J Orofac Pain 1998;12:210–218.

8. Fricton JR, Kroening RF, Hathaway KW. Temporomandibular Joint and Craniofacial Pain; Diagnosis and Management. St Louis: Ishiyaku EuroAmerica, 1988.

9. Fricton JR, Olsen T. Predictors of outcome for treatment of temporomandibular disorders. J Orofac Pain 1996;10:54–65.

10. Gerschman JA, Wright JL, Hall WD, Reade PC, Burrows GD, Holwill BJ. Comparisons of psychological and social factors in patients with chronic orofacial pain and dental phobic disorders. Aust Dent J 1987;32:331–335.

11. Dworkin SF, LeResche L. Research Diagnostic Criteria for Temporomandibular Disorders. J Craniomandib Disord Facial Oral Pain 1992;6:301–355.

12. Gale EN, Funch DP. Factors associated with successful outcome form behavioral therapy for chronic temporomandibular joint pain. J Psychosom Res 1984;28: 441–448.

13. Lipton JA, Marbach JJ. Predictors of treatment outcome in patients with myofascial pain-dysfunction syndrome and organic temporomandibular joint disorders. J Prosthet Dent 1984;51:387–393.

14. Pankhurst CL. Controversies in the aetiology of temporomandibular disorders. Part 1. Temporomandibular disorders: All in the mind? Prim Dent Care 1997;4:25–30.

15. Stuss DT, Ely P, Hugenholtz H, et al. Subtle neuropsychological deficits in patients with good recovery after closed head injury. Neurosurgery 1985;17:41–47.

16. Stuss DT, Stethem LL, Poirier CA. Comparison of three tests of attention and rapid information processing across six age groups. Clin Neuropsychol 1987;1:139–152.

17. Goldberg MB, Mock D, Ichise M, et al. Neuropsychologic deficits and clinical features of posttraumatic temporomandibular disorders. J Orofacial Pain 1996;10:126–140.

18. Romanelli GG, Mock D, Tenenbaum HC. Characteristics and response to treatment of posttraumatic temporomandibular disorders: A retrospective study. Clin J Pain 1992;8:6–17.

19. Dao TT, Lavigne GJ, Charbonneau A, Feine JS, Lund JP. The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles: A controlled clinical trial. Pain 1994;56:85–94.

20. Price DD, Bush FM, Long S, Hawkins SW. A comparison of pain measurement characteristics of mechanical visual analogueand simple numerical rating scales. Pain 1994;56:217–226.

21. Folkard S, Glynn CJ, Lloyd JW. Diurnal variation and individual differences in the perception of intractable pain. J Psychosom Res 1976;20:289–301.

22. Stuss DT, Stethem LL, Hugenholtz H, Richard MT. Traumatic brain injury: A comparison of three clinical tests, and analysis of recovery. Clin Neuropsychol 1989;3:145–156.

23. Delis D, Kramer JH, Kaplan E, Ober BA. California Verbal Learning test. Psychological Corporation, 1987.

24. Peterson LR, Peterson MJ. Short-term retention of individual verbal items. J Exper Psychol 1959;58:193–226.

25. Beck AT. Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press, 1970.

26. Cesta A, Moldofsky H, Sammut C. The University of Toronto sleep assessment questionnaire (SAQ). Sleep Res 1996;25:486.

27. Taylor W. How to use guide to sample size calculation. In: Taylor W, (ed) Hamilton, Ontario, Canada: McMaster University Press, 1981.

28. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–174.

29. Stuss DT, Stethem LL, Hugenholtz H, Picton T, Pivik J, Richard MT. Reaction time after head injury: Fatigue, divided and focused attention, and consistency of performance. J Neurol Neurosurg Psychiatry 1989;52:742–748.

30. Hennekens CH, Buring JE. Epidemiology in Medicine. Boston: Little, Brown, 1987.

31. Schnurr RF, Rollman GB, Brooke RI. Are there psychologic predictors of treatment outcome in temporomandibular joint pain and dysfunction? Oral Surg Oral Med Oral Pathol 1991;72:550–558.

32. Magnusson T, List T, Helkimo M. Self-assessment of pain and discomfort in patients with temporomandibular disorders: A comparison of five different scales with respect to their precision and sensitivity as well as their capacity to register memory of pain and discomfort. J Oral Rehabil 1995;22:549–556.

33. Millstein-Prentky S, Olson RE. Predictability of treatment outcome in patients with myofascial pain-dysfunction (MPD) syndrome. J Dent Res 1979;58:1341–1346.

34. Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain 1983;16:87–101.

35. Whitney CW, Dworkin SF. Practical implications of noncompliance in randomized clinical trials for temporomandibular disorders. J Orofac Pain 1997;11:130–138.

36. Dworkin SF. Behavioral and educational modalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:128–133.

37. Oakley ME, McCreary CP, Clark GT, Holston S, Glover D, Kashima K. A cognitive-behavioral approach to temporomandibular dysfunction treatment failures: A controlled comparison. J Orofac Pain 1994;8:397–401.

38. Greco CM, Rudy TE, Turk DC, Herlich A, Zaki HH. Traumatic onset of temporomandibular disorders: Positive effects of a standardized conservative treatment program. Clin J Pain 1997;13:337–347.

39. DeNucci DJ, Sobiski C, Dionne RA. Triazolam improves sleep but fails to alter pain in TMD patients. J Orofac Pain 1998;12:116–123.

40. Dworkin SF, LeResche L, von Korff M, Truelove E, Sommers E. Predicting continued presence and level of temporomandibular disorder pain. J Dent Res 1989;68:194.

41. Dworkin SF, LeResche L, von Korff M, Dicker B, Sommers E. Constant, remitted and cyclic pain patterns in temporomandibular disorder: Three-year follow-up. J Dent Res 1991;70:441.

42. Nielsen AC, Williams TA. Depression in ambulatory medical patients: Prevalence by self-report questionnaire and recognition by non-psychiatric physicians. Arch Gen Psychiatry 1980;37:999–1004.

43. Laskin DM. Headache and the aching jaw [editorial]. J Oral Maxillofac Surg 1983;41:420.

44. Wilson L, Dworkin SF, Whitney C, LeResche L. Somatization and pain dispersion in chronic temporomandibular disorder pain. Pain 1994;57:55–61.

45. Carlsson GE, Egermark-Eriksson I, Magnusson T. Intra-and inter-observer variation in functional examination of the masticatory system. Swed Dent J 1980;4:187–194.

46. Linton SJ, Melin L. The accuracy of remembering chronic pain. Pain 1982;13:281–285.

47. Freeman BV, Psutka DJ, Hunter JJ, Baker GI. Arthroscopy of the temporomandibular joint: A comparison of objective and subjective outcome measures in patients with and without evidence of a psychopathologic disorder. Alpha Omegan 1998;91:44–50.

48. Davis KD, Taylor SJ, Crawley AP, Wood ML, Mikulis DJ. Functional MRI of pain- and attention-related activations in the human cingulate cortex. J Neurophysiol 1997;77:3370–3380.

49. Epker J, Gatchel RJ, Ellis E III. A model for predicting chronic TMD: Practical application in clinical settings. J Am Dent Assoc1999;130:1470–1475.

50. Goldstein BH. Medical legal considerations in temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:395–399.

51. Talo S, Rytokoski U, Hamalainen A, Kallio V. The biopsychosocial disease consequence model in rehabilitation: Model development in the Finnish ‘work hardening’ programme for chronic pain [see comments]. Int J Rehabil Res 1996;19:93–109.

52. Tenenbaum HC, Freeman BV, Psutka DJ, Baker GI. Temporomandibular disorders: Disc displacements. J Orofac Pain 1999;13:285–290.

53. Sikes RW, Vogt BA. Nociceptive neurons in area 24 of rabbit cingulate cortex. J Neurophysiol 1992;68: 1720–1732.

54. Pillay PK, Hassenbusch SJ. Bilateral MRI-guided stereotactic cingulotomy for intractable pain. Stereotact Funct Neurosurg 1992;59:33–38.