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Centre for Evidence-
Based Medicine

Temporomandibular Joint Disorders: Clinical exam may be helpful in the diagnosis

Clinical Bottom Line

If the pre-test probability is intermediate (e.g. 50%), the post-test probability for positive test results increases to 81%. The validity of the reference standard was not specified in the article; there is evidence that MRI may be the best reference standard.

Citation

Schiffman EL, Anderson GC, Fricton JR, Burton K, Schellhas KP. Diagnostic criteria for intrarticular temporomandibular disorders. Community Dent Oral Epidemiol 1989;17:252-257.

Clinical Question

Is your clinical diagnosis of: internal derangement correct when presented with a patient with the following clinical [history of locking, preauricular pain, reproducible and reciprocal click, reduced mouth opening (35 mm), local muscle tenderness, reduced joint play] and tomography findings (diminished anterior translation of both condyles, no osseous changes)?

Search Terms

You do a MEDLINE search (1988 - 1998) using the MESH heading 'temporomandibular joint disorders' you find one article assessing a cluster of clinical tests and tomography.

The Study

  1. Gold Standard - A reference test (arthrotomography) was used. A blind comparison was made. However, it was not clear if the reference test was performed independently of the clinical tests. The validity of the reference standard was not specified.
  2. Study Setting - tertiary care

The Evidence

Diagnostic Criteria Internal Derangement No Internal Derangement Likelihood Ratio
Present 43/50 2/10 4.30
Absent 7/50 8/10 0.18
50 10

If the pre-test probability is intermediate (e.g. 50%) then a positive clinical test would be helpful, yielding a post-test probability of 81%.

If the pre-test probability is low (e.g. 20 %) then the clinical test is not useful (post-test probability = 52%).

Comments

  1. Diagnostic test: diagnostic criteria for intraarticular TM disorder (Table 3 of the paper) included positive history of mandibular limitation, no reciprocal click, no coarse crepitus, maximum opening less than or equal to 35 mm, passive opening stretch less than 40 mm, contralateral movement less than 7 mm, no S-curve deviation and tomography findings of decreased translation of the ipsilateral condyle.
  2. Uncertain if the reference standard that was used was the best available
  3. Unclear if the reference standard performed independently of the clinical tests

Appraised By

Anita Gross; February 16, 1999.

Expiry Date

2001