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The chapter delves into the complexities of diagnosing Temporomandibular Disorders (TMDs) and Orofacial Pain (OP), which are often misdiagnosed due to their symptom overlap with more severe conditions. It highlights the inadequacies of traditional diagnostic models like the Research Diagnostic Criteria (RDC) and the Bayesian statistical models in handling the variable nature of TMD symptoms and the influence of cognitive biases in diagnostic processes. | |||
The narrative starts by questioning the variability in TMD prevalence rates reported in different studies worldwide, suggesting potential flaws in study designs and statistical methods. It introduces the concept that classical statistical approaches, such as Bayes' Theorem, are insufficient for TMD diagnostics because they cannot adequately handle the non-compatible variables involved in these complex disorders. | |||
The text explains the need for a new paradigm in diagnosing TMDs that considers both the clinical symptoms and the underlying neuromuscular issues. This approach is illustrated through the discussion of two new patients, highlighting how previous diagnoses based on outdated criteria could lead to misdiagnosis and inappropriate treatments. These case studies serve to underscore the potential dangers of relying solely on symptomatic diagnosis without a deeper understanding of the neuromuscular components. | |||
Furthermore, the chapter critiques the reliance on the RDC model, suggesting that it falls short in differentiating between TMD sufferers and healthy individuals due to its strict criteria that do not account for the nuanced reality of patient symptoms. It calls for a consortium network approach, involving multiple studies and expert opinions to develop a more accurate and flexible diagnostic framework. | |||
The discussion extends into the realm of cognitive psychology, where it is noted that the order of information presentation can significantly affect diagnostic outcomes. This cognitive bias can lead clinicians to different conclusions depending on the sequence of diagnostic data presented, a concept not accounted for in traditional Bayesian statistics but potentially explainable by quantum probability theory. | |||
The chapter concludes by advocating for a more interdisciplinary approach to diagnosing and treating TMDs, suggesting that the integration of dental and neurological expertise is crucial. It proposes moving beyond traditional diagnostic models towards a system that embraces the complexity of TMDs and utilizes a broader spectrum of scientific insights to enhance diagnostic accuracy and patient care. | |||
In summary, this text pushes for a revolution in how TMDs are understood and diagnosed, arguing for the abandonment of outdated statistical models and the adoption of new methodologies that reflect the complex, interrelated nature of neuromuscular and cognitive factors in TMDs. This approach aims not only to improve diagnostic accuracy but also to foster a more holistic understanding of patient care in the field of orofacial pain management.<blockquote> | |||
== Keywords == | |||
'''Temporomandibular Disorders (TMDs)''' - This keyword is crucial as the chapter discusses the complexity and diagnostic challenges associated with TMDs. | |||
'''Orofacial Pain''' - Essential for targeting discussions and content around the pain related to facial muscles, joints, and related structures, which is a central theme in the chapter. | |||
'''Diagnostic Challenges in TMD''' - Highlights the main focus on the difficulties faced by healthcare professionals in accurately diagnosing TMDs due to overlapping symptoms with other conditions. | |||
'''Neuromuscular Disorders Diagnosis''' - Relevant for content discussing the importance of understanding neuromuscular components in diagnosing conditions like TMDs. | |||
'''Research Diagnostic Criteria (RDC)''' - Targets discussions about the limitations and application of RDC in diagnosing TMDs, which the chapter critiques. | |||
'''Bayesian Statistics in Medical Diagnostics''' - Focuses on the inadequacy of traditional Bayesian methods in the context of complex medical diagnoses, particularly TMDs. | |||
'''Cognitive Biases in Diagnostics''' - Appropriate for content that explores how the sequence of information presentation can influence medical diagnosis, a significant point made in the chapter. | |||
'''Quantum Probability in Medicine''' - Suitable for innovative diagnostic approaches that go beyond classical statistical methods, reflecting the chapter’s push for newer models in medical decision-making. | |||
'''Interdisciplinary Approach to TMD''' - Emphasizes the chapter's call for integrating dental and neurological expertise in diagnosing and treating TMDs. | |||
'''Clinical Symptoms of TMD''' - Important for content focusing on the specific symptoms that characterize TMD and how they overlap with other medical issues.</blockquote> | |||
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=== Introduction === | ===Introduction=== | ||
During the previous chapters of Masticationpedia we wanted to highlight the diagnostic complexity in the field of Orofacial Pain and Temporomandibular Disorders (TMDs) which sometimes hide much more serious neurological and/or systemic pathologies with a diagnostic course of decades. One of the most striking data that emerges from research in the literature is the high prevalence of TMD (30%-50%) throughout the world<ref>Ouanounou A, Goldberg M, Haas DA. Pharmacotherapy in '''Temporomandibular''' '''Disorders''': A '''Review'''. J Can Dent Assoc. 2017 Jul;83:h7.</ref> combined with their variability between clinical studies (3-20%)..<ref>Poveda Roda R, Bagan JV, Díaz Fernández JM, Hernández Bazán S, Jiménez Soriano Y. '''Review''' of '''temporomandibular''' '''joint''' pathology. Part I: classification, '''epidemiology''' and risk factors. Med Oral Patol Oral Cir Bucal. 2007 Aug 1;12(4):E292-8.</ref><ref>Türp JC, Schindler HJ.Schmerz. Chronic '''temporomandibular''' '''disorders''']. 2004 Apr;18(2):109-17. doi: 10.1007/s00482-003-0279-x.PMID: 15067530 </ref><ref>Fricton JR. The relationship of '''temporomandibular''' '''disorders''' and fibromyalgia: implications for diagnosis and treatment. Curr Pain Headache Rep. 2004 Oct;8(5):355-63. doi: 10.1007/s11916-996-0008-0.PMID: 15361319 </ref><ref>De Meyer MD, De Boever JA.The role of bruxism in the appearance of '''temporomandibular''' '''joint''' '''disorders'''].Rev Belge Med Dent (1984). 1997;52(4):124-38. PMID: 9709800 | During the previous chapters of Masticationpedia we wanted to highlight the diagnostic complexity in the field of Orofacial Pain and Temporomandibular Disorders (TMDs) which sometimes hide much more serious neurological and/or systemic pathologies with a diagnostic course of decades. One of the most striking data that emerges from research in the literature is the high prevalence of TMD (30%-50%) throughout the world<ref>Ouanounou A, Goldberg M, Haas DA. Pharmacotherapy in '''Temporomandibular''' '''Disorders''': A '''Review'''. J Can Dent Assoc. 2017 Jul;83:h7.</ref> combined with their variability between clinical studies (3-20%)..<ref>Poveda Roda R, Bagan JV, Díaz Fernández JM, Hernández Bazán S, Jiménez Soriano Y. '''Review''' of '''temporomandibular''' '''joint''' pathology. Part I: classification, '''epidemiology''' and risk factors. Med Oral Patol Oral Cir Bucal. 2007 Aug 1;12(4):E292-8.</ref><ref>Türp JC, Schindler HJ.Schmerz. Chronic '''temporomandibular''' '''disorders''']. 2004 Apr;18(2):109-17. doi: 10.1007/s00482-003-0279-x.PMID: 15067530 </ref><ref>Fricton JR. The relationship of '''temporomandibular''' '''disorders''' and fibromyalgia: implications for diagnosis and treatment. Curr Pain Headache Rep. 2004 Oct;8(5):355-63. doi: 10.1007/s11916-996-0008-0.PMID: 15361319 </ref><ref>De Meyer MD, De Boever JA.The role of bruxism in the appearance of '''temporomandibular''' '''joint''' '''disorders'''].Rev Belge Med Dent (1984). 1997;52(4):124-38. PMID: 9709800 | ||
</ref> | </ref> | ||
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{{q2|........further research and development will benefit from a programmatic approach that is inclusive of the multiple directions described here as well as countless others that exist outside the current consortium framework|Let's look at some relevant passages}} | {{q2|........further research and development will benefit from a programmatic approach that is inclusive of the multiple directions described here as well as countless others that exist outside the current consortium framework|Let's look at some relevant passages}} | ||
==== Prevalence of TMDs ==== | ====Prevalence of TMDs ==== | ||
The prevalence of temporomandibular disorder (TMDs) symptoms varies significantly between populations. | The prevalence of temporomandibular disorder (TMDs) symptoms varies significantly between populations. | ||
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Furthermore, most of the previous studies on the association of TMD-related pain and headache have been based on 'Frequencyist' statistics, models which, compared to the Bayesian approach, suffer from some limitations, especially the dependence on large samples so that effect sizes are precisely determined.<ref name=":0">Buchinsky FJ, Chadha NK. To P or not to P: backing Bayesian statistics. Otolaryngol Head Neck Surg. 2017;157(6):915–918. doi: 10.1177/0194599817739260.</ref><blockquote>According to Javed Ashraf et al.<ref name=":1">Javed Ashraf, Matti Närhi, Anna Liisa Suominen, Tuomas Saxlin. Association of temporomandibular disorder-related pain with severe headaches-a Bayesian view. Clin Oral Investing. 2022 Jan;26(1):729-738. doi: 10.1007/s00784-021-04051-y. Epub 2021 Jul 5.</ref> contrary to the 'Frequencyist' methodology, Bayesian statistics does not provide a (fixed) result value but rather an interval containing the regression coefficient.<ref>Depaoli S, van de Schoot R. Bayesian analyses: where to start and what to report. Eur Heal Psychol. 2014;16:75–84.</ref> These intervals, called confidence intervals (CI), assign a probability to the best estimate and to all possible values of the parameter estimates.<ref name=":0" /></blockquote>In the study by Javed Ashraf et al.<ref name=":1" /> the authors using Bayesian methodology, attempted to verify the existence of the correlation between TMD-related pain with severe headaches (migraine and TTH) over an 11-year follow-up period. The Health 2000 survey, conducted in 2000 and 2001, included 9922 invited participants aged 18 years and older living in mainland Finland.<ref>Aromaa A, Koskinen S (2004) Health and functional capacity in Finland. Baseline results of the Health 2000 Health Examination Survey. Publications of the National Public Health Institute B12/2004. Helsinki</ref> The prospective association of mTMD at baseline with the presence of TTH at follow-up found in the present study is in line with previous epidemiological, clinical and physiological evidence. Previous epidemiological studies have shown an association between TMD-related pain and TTH.<ref>Ciancaglini R, Radaelli G. The relationship between headache and symptoms of temporomandibular disorder in the general population. J Dent. 2001;29:93–98. doi: 10.1016/S0300-5712(00)00042-7</ref> Clinically, TMD-related pain and TTH share a combination of distinct signs and symptoms in the head and facial region, particularly evident regarding mTMD and TTH. These common clinical features include tenderness on palpation of the masticatory muscles in the case of mTMD and of the pericranial muscles in the case of TTH during the active phases of both conditions.<ref>Bendtsen L, Ashina S, Moore A, Steiner TJ. Muscles and their role in episodic tension-type headache: implications for treatment. Eur J Pain. 2016;20:166–175. doi: 10.1002/ejp.748.</ref> Other clinical intersections between mTMD and TTH include age of subjects regarding peak prevalence,<ref>Costa Y-M, Porporatti A-L, Calderon P-S, Conti P-C-R, Bonjardim L-R. Can palpation-induced muscle pain pattern contribute to the differential diagnosis among temporomandibular disorders, primary headaches phenotypes and possible bruxism? Med oral, Patol oral y cirugía bucal. 2016;21:e59–65. doi: 10.4317/medoral.20826.</ref> pain intensity, pharmacotherapy,<ref>Neblett R, Cohen H, Choi Y, Hartzell MM, Williams M, Mayer TG, Gatchel RJ. The central sensitization inventory (CSI): establishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. J Pain. 2013;14:438–445. doi: 10.1016/j.jpain.2012.11.012.</ref> and even non-pharmacological treatment.<ref>Fernández-De-Las-Peñas C, Cuadrado ML. Physical therapy for headaches. Cephalalgia. 2016;36:1134–1142. doi: 10.1177/0333102415596445.</ref> Despite some clinical similarities and overlap, both mTMD and TTH are distinct disease entities and Javed Ashraf<ref name=":1" /> elegantly concludes: | Furthermore, most of the previous studies on the association of TMD-related pain and headache have been based on 'Frequencyist' statistics, models which, compared to the Bayesian approach, suffer from some limitations, especially the dependence on large samples so that effect sizes are precisely determined.<ref name=":0">Buchinsky FJ, Chadha NK. To P or not to P: backing Bayesian statistics. Otolaryngol Head Neck Surg. 2017;157(6):915–918. doi: 10.1177/0194599817739260.</ref><blockquote>According to Javed Ashraf et al.<ref name=":1">Javed Ashraf, Matti Närhi, Anna Liisa Suominen, Tuomas Saxlin. Association of temporomandibular disorder-related pain with severe headaches-a Bayesian view. Clin Oral Investing. 2022 Jan;26(1):729-738. doi: 10.1007/s00784-021-04051-y. Epub 2021 Jul 5.</ref> contrary to the 'Frequencyist' methodology, Bayesian statistics does not provide a (fixed) result value but rather an interval containing the regression coefficient.<ref>Depaoli S, van de Schoot R. Bayesian analyses: where to start and what to report. Eur Heal Psychol. 2014;16:75–84.</ref> These intervals, called confidence intervals (CI), assign a probability to the best estimate and to all possible values of the parameter estimates.<ref name=":0" /></blockquote>In the study by Javed Ashraf et al.<ref name=":1" /> the authors using Bayesian methodology, attempted to verify the existence of the correlation between TMD-related pain with severe headaches (migraine and TTH) over an 11-year follow-up period. The Health 2000 survey, conducted in 2000 and 2001, included 9922 invited participants aged 18 years and older living in mainland Finland.<ref>Aromaa A, Koskinen S (2004) Health and functional capacity in Finland. Baseline results of the Health 2000 Health Examination Survey. Publications of the National Public Health Institute B12/2004. Helsinki</ref> The prospective association of mTMD at baseline with the presence of TTH at follow-up found in the present study is in line with previous epidemiological, clinical and physiological evidence. Previous epidemiological studies have shown an association between TMD-related pain and TTH.<ref>Ciancaglini R, Radaelli G. The relationship between headache and symptoms of temporomandibular disorder in the general population. J Dent. 2001;29:93–98. doi: 10.1016/S0300-5712(00)00042-7</ref> Clinically, TMD-related pain and TTH share a combination of distinct signs and symptoms in the head and facial region, particularly evident regarding mTMD and TTH. These common clinical features include tenderness on palpation of the masticatory muscles in the case of mTMD and of the pericranial muscles in the case of TTH during the active phases of both conditions.<ref>Bendtsen L, Ashina S, Moore A, Steiner TJ. Muscles and their role in episodic tension-type headache: implications for treatment. Eur J Pain. 2016;20:166–175. doi: 10.1002/ejp.748.</ref> Other clinical intersections between mTMD and TTH include age of subjects regarding peak prevalence,<ref>Costa Y-M, Porporatti A-L, Calderon P-S, Conti P-C-R, Bonjardim L-R. Can palpation-induced muscle pain pattern contribute to the differential diagnosis among temporomandibular disorders, primary headaches phenotypes and possible bruxism? Med oral, Patol oral y cirugía bucal. 2016;21:e59–65. doi: 10.4317/medoral.20826.</ref> pain intensity, pharmacotherapy,<ref>Neblett R, Cohen H, Choi Y, Hartzell MM, Williams M, Mayer TG, Gatchel RJ. The central sensitization inventory (CSI): establishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. J Pain. 2013;14:438–445. doi: 10.1016/j.jpain.2012.11.012.</ref> and even non-pharmacological treatment.<ref>Fernández-De-Las-Peñas C, Cuadrado ML. Physical therapy for headaches. Cephalalgia. 2016;36:1134–1142. doi: 10.1177/0333102415596445.</ref> Despite some clinical similarities and overlap, both mTMD and TTH are distinct disease entities and Javed Ashraf<ref name=":1" /> elegantly concludes: | ||
{{q2|Although the mix of similarities may require close interdisciplinary cooperation between specialties (dentistry vs neurology), vigilance should also be exercised regarding the distinction between these two pathological entities during their treatment.|'Interdisciplinarity' means 'Context'}} | |||
==== Contexts ==== | ==== Contexts==== | ||
In the previous chapters of Masticationpedia, when describing the diagnostic complexity we took into consideration a fact that will be essential: the contexts. We have seen how a symptomatic or asymptomatic sick person places himself before the doctor who, listening to his story, tries to reconstruct the progress of the 'state' of the organic system to reach a certain diagnosis. At the same time, however, we also considered the enormous distance in clinical scientific knowledge between a context, the dental one, and the neurological one. These contexts employing a formal logic arrive at the conviction of their diagnostic reason. The assumption is that the assertions that contribute to building this certainty are very different between contexts. For this reason in the chapter '[[Fuzzy language logic]]' we considered a set <math>\tilde{A}</math> and a membership function <math>\mu_{\displaystyle {\tilde {A}}}(x)</math>. | In the previous chapters of Masticationpedia, when describing the diagnostic complexity we took into consideration a fact that will be essential: the contexts. We have seen how a symptomatic or asymptomatic sick person places himself before the doctor who, listening to his story, tries to reconstruct the progress of the 'state' of the organic system to reach a certain diagnosis. At the same time, however, we also considered the enormous distance in clinical scientific knowledge between a context, the dental one, and the neurological one. These contexts employing a formal logic arrive at the conviction of their diagnostic reason. The assumption is that the assertions that contribute to building this certainty are very different between contexts. For this reason in the chapter '[[Fuzzy language logic]]' we considered a set <math>\tilde{A}</math> and a membership function <math>\mu_{\displaystyle {\tilde {A}}}(x)</math>. | ||
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Let's imagine that <math>\mu_{\displaystyle {\tilde {A}}}(x)</math> it represents a context and that it is a continuous function defined in the range <math>[0;1]</math> where: | Let's imagine that <math>\mu_{\displaystyle {\tilde {A}}}(x)</math> it represents a context and that it is a continuous function defined in the range <math>[0;1]</math> where: | ||
*<math>\mu_ {\tilde {A}}(x) = 1\rightarrow </math>if it is totally contained in <math>A</math> (these points are called 'nucleus', they indicate the plausible values of the predicate). | *<math>\mu_ {\tilde {A}}(x) = 1\rightarrow </math>if it is totally contained in <math>A</math> (these points are called 'nucleus', they indicate the plausible values of the predicate). | ||
*<math>\mu_ {\tilde {A}}(x) = 0\rightarrow </math> if <math>x</math> it is not contained in <math>A</math> | *<math>\mu_ {\tilde {A}}(x) = 0\rightarrow </math> if <math>x</math> it is not contained in <math>A</math> | ||
*<math>0<\mu_ {\tilde {A}}(x) < 1 \;\rightarrow </math> if <math>x</math> it is partially contained in <math>A</math> (these points are called 'Support set' <nowiki/>and indicate the possible values of the predicate possible predicate values). | * <math>0<\mu_ {\tilde {A}}(x) < 1 \;\rightarrow </math> if <math>x</math> it is partially contained in <math>A</math> (these points are called 'Support set' <nowiki/>and indicate the possible values of the predicate possible predicate values). | ||
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We will note the following deductions: | We will note the following deductions: | ||
* '''Classical logic''' in the dental context <math>{A}</math> in which only a logical process that gives <math>\mu_{\displaystyle {{A}}}(x)= 1 </math> as a result will be possible, i.e. <math>\mu_{\displaystyle {{A}}}(x)= 0 </math> the data range being <math>D=\{\delta_1,\dots,\delta_4\}</math> reduced to basic knowledge <math>KB</math> (dental scientific/clinical context) as a whole <math>{A}</math>. This means that outside the dental world or context there is a void and that the term set theory is written exactly <math>\mu_{\displaystyle {{A}}}(x)= 0 </math>and that it is synonymous with 'diagnostic risk'. | *'''Classical logic''' in the dental context <math>{A}</math> in which only a logical process that gives <math>\mu_{\displaystyle {{A}}}(x)= 1 </math> as a result will be possible, i.e. <math>\mu_{\displaystyle {{A}}}(x)= 0 </math> the data range being <math>D=\{\delta_1,\dots,\delta_4\}</math> reduced to basic knowledge <math>KB</math> (dental scientific/clinical context) as a whole <math>{A}</math>. This means that outside the dental world or context there is a void and that the term set theory is written exactly <math>\mu_{\displaystyle {{A}}}(x)= 0 </math>and that it is synonymous with 'diagnostic risk'. | ||
* '''Fuzzy logic''' in the world <math>\tilde{A}</math> in which not only the basic knowledge <math>KB</math> of the dental context but also those partially acquired from the neurophysiological world are represented, we have that the membership function will be determined by the summation of the two contexts <math>{A}</math> and <math>\tilde{A}</math>. In this scenario the membership function will always be within the range <math>0<\mu_ {\tilde {A}}(x) < 1</math> but the output data will correspond to the sum of the two contexts, obviously decreasing the diagnostic risk. | *'''Fuzzy logic''' in the world <math>\tilde{A}</math> in which not only the basic knowledge <math>KB</math> of the dental context but also those partially acquired from the neurophysiological world are represented, we have that the membership function will be determined by the summation of the two contexts <math>{A}</math> and <math>\tilde{A}</math>. In this scenario the membership function will always be within the range <math>0<\mu_ {\tilde {A}}(x) < 1</math> but the output data will correspond to the sum of the two contexts, obviously decreasing the diagnostic risk. | ||
{{q2|Well then we are already one step ahead. We understood that beyond the RDC model, contexts are fundamental for diagnosis.|.....yes, certainly a small step forward if there wasn't another little-considered obstacle, that of the 'Information Order' of the contexts}} | {{q2|Well then we are already one step ahead. We understood that beyond the RDC model, contexts are fundamental for diagnosis.|.....yes, certainly a small step forward if there wasn't another little-considered obstacle, that of the 'Information Order' of the contexts}} | ||
==== Order of information==== | ====Order of information==== | ||
The order of information plays a crucial role in the process of updating beliefs over time. In fact, the presence of order effects makes a classical or Bayesian approach to inference difficult. | The order of information plays a crucial role in the process of updating beliefs over time. In fact, the presence of order effects makes a classical or Bayesian approach to inference difficult. | ||
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This means that for Bayes the probability of being ill with a certain disease (Positive Predictive Value) does not change if the order of presentation of the information is reversed since in Bayes the variables <math>A</math> and <math>B</math> commute because they are compatible. As mentioned, if we change the order of presentation of the information the result does not change while at a cognitive decision-making level things are not exactly like that. Changing the order of presentation of the information can completely change the hypothesis, moving towards a diagnosis of neuropathy rather than TMD. | This means that for Bayes the probability of being ill with a certain disease (Positive Predictive Value) does not change if the order of presentation of the information is reversed since in Bayes the variables <math>A</math> and <math>B</math> commute because they are compatible. As mentioned, if we change the order of presentation of the information the result does not change while at a cognitive decision-making level things are not exactly like that. Changing the order of presentation of the information can completely change the hypothesis, moving towards a diagnosis of neuropathy rather than TMD. | ||
{{q2|So how can the problem be solved?|......with the usual Hamletic doubt: who says that the asymmetry of the trigeminal responses are compatible with a TMD?}} | |||
In quantum theory, events can be defined as compatible or incompatible. In the case where all events are compatible, quantum probability is identical to classical probability. Deciding when two events should be treated as compatible or incompatible is an important research question. In a very interesting article Jennifer S. Trueblood and Jerome R. Busemeyer<ref>Jennifer S. Trueblood, Jerome R. Busemeyer. A Quantum Probability Account of Order Effects in Inference. Cognitive Science Volume 35, Issue 8 p. 1518-1552. <nowiki>https://doi.org/10.1111/j.1551-6709.2011.01197.x</nowiki> | In quantum theory, events can be defined as compatible or incompatible. In the case where all events are compatible, quantum probability is identical to classical probability. Deciding when two events should be treated as compatible or incompatible is an important research question. In a very interesting article Jennifer S. Trueblood and Jerome R. Busemeyer<ref>Jennifer S. Trueblood, Jerome R. Busemeyer. A Quantum Probability Account of Order Effects in Inference. Cognitive Science Volume 35, Issue 8 p. 1518-1552. <nowiki>https://doi.org/10.1111/j.1551-6709.2011.01197.x</nowiki> | ||