Exploring temporomandibular disorders : longitudinal and qualitative perspectives

Sammanfattning: Background: Ideally, all clinical decision-making should enable care provision on the best available scientific evidence, clinical experience, and evaluated risks and benefits. Even though there are validated and evaluated decision tools for identification, diagnostics and treatment of temporomandibular disorders (TMD), patients with TMD still seem to go undetected, undiagnosed and undertreated in dentistry. Reasons for this discrepancy are unclear, but this clearly is a disadvantage for patients with TMD. Therefore, this project aimed to explore TMD in relation to the longitudinal course of the symptoms, dentists’ decision-making, and patients’ experiences.Methods: The project was conducted at the Public Dental Health Services in the Region of Västerbotten, Northern Sweden. Data in the longitudinal studies were based on the screening instrument for TMD, the 3Q/TMD, and included self-reported orofacial pain and jaw dysfunction, specifically jaw catching/locking, from 2010 to 2017 (n=180,308; age 5-104). Descriptive statistics, generalized estimating equation models, and Poisson regression were used for analyses. Data included in the qualitative studies were the transcribed individual interviews with dentists (n=22, age 25-64) and patients (n=16, age 20-65). Analyses were based on the Grounded Theory and the Qualitative Context Analysis.Results: The prevalence of orofacial pain increased over time (p<.01), but the prevalence of jaw catching/locking remained similar. The incidence, prevalence, and persistence of orofacial pain and jaw catching/locking were significantly higher in women than in men (p<.01). Women were at a higher risk for reporting both the first onset and the persistent orofacial pain (IRR 2.37; 95% CI, 2.25-2.50 and IRR 2.56; 95% CI, 2.28-2.87, respectively), and jaw catching/locking (IRR 2.29; 95% CI, 2.11-2.49 and IRR 2.32; 95% CI, 2.04-2.63, respectively) when compared to men. The onset of pain or jaw catching/locking was mostly independent and exclusive, i.e. without the other symptom (84.1%), and was higher for orofacial pain (64.9%) than for jaw catching/locking (19.2%). The decision-making process in the management of TMD was illustrated as an interplay between internal and external elements, where the dentists wished to apply professional knowledge but identified organizational obstacles and lack of self-confidence in their clinical decision-making for TMD. The patients expressed worry and social discomfort as a consequence of TMD. However, they strived to deal with the symptoms on their own as long as possible before seeking help. The challenges to access dental care and to receive suitable management were acknowledged. The right care at the right time was identified more like a wish than a current state of perceived TMD management.Conclusions: The observed longitudinal patterns of orofacial pain and jaw dysfunction indicate increasing prevalence of orofacial pain together with substantial gender differences in TMD. The finding of independent onset of jawcatching/locking and orofacial pain reinforces that these two differ in the pathophysiology. The challenges in decision-making for patients with TMD and perceived suboptimal management of TMD symptoms are partly related to the structural organization of the Public Dental Health Services. Thus, careful review of the current organization is warranted since the treatment-need related to orofacial pain will probably increase.