Fathima N, Dharman S. Role of Thermography in Assessment of Myogenous Temperomandibular Disorders. Biomed Pharmacol J 2019;12(3).

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Manuscript received on :25-Jan-2019
Manuscript accepted on :20-Jul-2019
Published online on: 23-07-2019

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Nida Fathima¹ and Sreedevi Dharman²  

¹Saveetha Dental College, Saveetha Institute of Medical and Technical Science, Saveetha University, Chennai, 600053-India.

²Department of Oral Medicine and Radiology, Saveetha Dental College, Saveetha Institute of Medical and Technical Science, Saveetha University, Chennai, 600053-India.

Corresponding Author E-mail: sanjamrut@gmail.com

DOI : https://dx.doi.org/10.13005/bpj/1753

Abstract

The main objective of this review was to identity the usage of thermography in diagnosis of orofacial pain. Thermography is a method of measurement of skin temperature distribution on the body over a given period of time. Hence using the skin temperature, an advantages result can be obtained in identifying diseased condition in orofacial region. This article highlights the basics of thermography as a diagnostic tool in dentistry in identifying orofacial pain.  PUBMED and Google Scholar were searched to identify all the clinical trials which evaluated the use of thermography in diagnosis of orofacial pain. The included studies involved 6 clinical trials. From all the included studies, an advantages result was obtained by using thermography in assessing orofacial disorders between symptomatic and asymtomatic patient’s. All the findings obtained, suggest that thermography can be helpful in evaluating myogenous temperomandibular joint disorder and can be used as a clinical screening method and for improving diagnostic accuracy. In few studies, the sensitivity of thermography in the diagnosis of orofacial disorder is low, but has high specificity which helped in evaluation of orofacial disorder and is therefore applicable to patients with orofacial pain. Thermography benefits by locating the temperature difference between symptomatic and asymtomatic facial region thus indicating its aid  in diagnoses of orofacial disorder. However due to liminted evidence and short term studies, it is recommended that more of long term studies with large sample size should be emphasised to use thermography as routine diagnostic tool in identifying orofacial disorder.

Keywords

Asymtomatic Facial; Emphasised; Orofacial Disorder; Thermography

Introduction

Orofacial pain disorders are highly prevalent and debilitating conditions involving the head, face, and neck. These conditions represent a challenge to the clinician since the orofacial region is complex and therefore, pain can arise from many sources. The clinician needs to have solid knowledge of the pain conditions that arise from these structures for proper diagnosis and a multidisciplinary approach of management is strongly recommended.

Temperomandibular disorder (TMD) defines a number of clinical problems that involve the masticatory musculature, the TMJ, and associated structures.¹ TMD is considered to be a subclassification of musculoskeletal disorders² and is the most prevalent condition for which patients seek treatment.^3,4 The careful evaluation of these facial structures in conjunction with clinical symptoms is important in forming a proper differential diagnosis. The patient may present with jaw ache, earache, toothache, facial pain, and/or headache; however, the complaint may be as benign as general facial fullness or pressure. Treatment planning depend on various factors, including the chief complaint, medical history, presenting symptoms, examination, and diagnosis. The therapeutic methods offer patients a wide range of treatment modalities with higher success rates.

Thermology is the study and application of biothermal processes to assess health or disease and the word thermography employs imaging and visual evaluation of those thermal changes from an  object to detect, display, and record thermal patterns across the surface of the object.⁵

The thermography principle is as the amount of blood circulation at different layers of the skin varies, the temperature also changes accordingly. Consequently, disorders that affect the blood flow too result in abnormalities in temperature distribution and these when evaluated will provide valid diagnostic information.⁶

Based on the method of application, thermography can be classified into the following types⁷:

Semi‑quantitative contact method – liquid crystal thermography

Quantitative infrared‑detecting noncontact methods which are categorized as follows.

Infrared telethermography.

Dynamic telethermography.

Facial telethermography.

Thus the aim of this systematic review is to analyse the existing clinical trials of thermography role on diagnosis of orofacial pain.

Materials and Method

Search Strategy

Internet sources were used to search for appropriate papers that satisfied the study purpose. The total number of articles obtained are 26. PUBMED and Google Scholar were searched to identify all the clinical trials in which evaluates the use of thermography in diagnosis of orofacial pain. The current review article aims in evaluating the application of thermographs in diagnosis of orofacial pain mostly temperomandibular pain, hence the following inclusion and exclusion criteria was devised to select the appropriate clinical trial. The articles were screened on the basis of  title and abstract. Full text was then procured for the relevant articles which fulfilled the inclusion criteria. Only articles published in the English language were considered for this review. In  addition, the reference lists of the included articles were screened for additional relevant articles.

Eligibility Criteria

Inclusion Criteria

Randomized controlled clinical trials (RCTs), controlled clinical trials or case.

Papers written in English.

Studies conducted on humans.

Population: patients with symptomatic and Asymtomatic of TMD.

Clinical parameters: evidence in diagnosis of orofacial pain using thermography.

Exclusion Criteria

In-vitro studies, Animal studies, literature reviews. All irrelevant studies were excluded and the reasons for their exclusion were noted.

Outcome Measures

Values obtained by utilising thermography on symptomatic and asymtomatic patients of temperomandibular disorder containing orofacial pain.

Methodological Quality Assessment

Quality assessment was done for all the included articles. All the required data’s collected from the included studies were formulated showing the results and outcome measures. Table (1) contains the included articles used in this review and Table (2) contains the characteristics of thermography in orofacial pain.

Result

This systematic review includes 6 trials in which thermography is used in the diagnosis of orofacial pain mostly patient with TMD. The total number of patients included in all the five studies was 189. The major outcomes measured in these studies vary in temperature between symptomatic and asymtomatic patient’s. The results of these trials are tabulated as follows in Table 2. Krzysztof Woźniak et al [2015], in his trial, he obtained before chewing test showed  Tmax=36.01°C, ΔT=0.26°C and after chewing test showed Tmax= 36.31°C, ΔT= 0.52°C. Thus chewing test helped to increase the diagnostic efficiency of thermography in identifying patients with TMD.⁸ D S Hadda et al [2014] in his trial the result obtained were Absolute mean temperature for asymptomatic patient: anterior temporalis (34.78°C), masseter (33.48°C) and symptomatic patient: anterior temporalis (34.37°C), masseter (32.85°C). Thus temperature of facial cutaneous areas over the masseter and anterior temporalis muscles decreases in the presence of myogenous TMD.⁹ U. Snekhalatha et al [2018] in her trial obtained mean temperature for the normal group which was calculated was found out to be ≅31°c and that of abnormal group was calculated to be ≅34°c which ≅ 3°C more than normal subjects. Hence the skin surface temperature of the body, that is, the region of interest, is elevated.¹⁰ Dong-Joon Han et al [2001] in his trial resulted with mean temperature for TMJ: 28.22°C, Anterior  Temporalis: 28.32°C, Masseter anterior: 27.90°C, Masseter inferior: 27.89°C. Thus providing an effective diagnostic aid in evaluation of orofacial pain.¹¹ Ana C. S. Costa et al [2012] in his trial obtained an array of values showing patient’s with TMD: LMA=32.84°C, RMA=32.99°C, LAT=34.09°C, RAT=34.29°C, SHY=32.99°C, LUT= 32.60°c, RUT= 32.85°C. Patients Without TMD: LMA=32.67°C, RMA=32.65°C, LAT=34.22°C, RAT=34.21°C, SHY=33.02°C, LUT= 32.59°C, RUT= 32.57°C. Hence obtaining  intra and inter-rater reliability of the temperature measures of the masseter, anterior temporalis, supra-hyoid and upper trapezius muscles symptom were found to be slightly elevated in patient’s with TMD.¹²

According to all the trials, the thermographic value or the facial temperature of patient’s with orofacial pain was found to be raised than with that of symptomatic patient’s . However this studies  gives a weak evidence of the obtained result. The available in literature are short-term studies, hence Long-term studies are required with larger sample size to emphasize the use of thermographs in diagnosis of orofacial pain.

Figure 1: Flowchart showing search strategy.   Click here to view figure

Table 1: Article selected for systematic review.

Table 2: Characterisitics of included studies.   Click here to view table

Discussion

Thermography has many advantages – it is easy to use and non-invasive. However, there is a lack of standardized protocol for the temperature measurement of the masticatory muscles using infrared thermography. Gratt et al.^13,14 evaluated the orofacial region by establishing 5 measurement areas: small TMJ, large TMJ, mandible, midface, and entire half-face. In another study by Dibai Filho et al.,¹⁵ the measurement of skin surface temperature was done in the muscle central point.There is difference in the region of muscle temperature may be explained on the basis of anatomy: the temporalis muscle is thinner than the masseter muscle and is influenced by the superficial path of the temporalis artery, which makes the region more hyper-radiant.¹⁶

Currently thermal imaging techniques were used for the evaluation of various dental disorders by qualitative and quantitative methods. This technique is also used as research tool in the field of dentistry for identifying the root canal inflammation, cavitations and in the development of abscess. Asymptomatic dental issues can be diagnosed using thermography, as seen in the study with patients showing no apparent problems or complaints about pain or discomfort. In a study similar to findings by Merla et al wherein they distinguished between healthy patients and patients suffering from myofascial pain using functional infrared imaging.^17-19

The evaluation by the infrared thermography has some limitations, as the amount of subcutaneous fat, since this interferes in the skin surface temperature.²⁰ Furthermore, it is an indirect measure of the blood flow²¹ and of the activity of the autonomic nervous system.²² Gratt and his colleagues classified the patients with chronic orofacial pain as normal, hot or cold when the temperature in a selected anatomic area (∆T) fell between certain assigned ranges.²³

The symmetry of temperature distribution in the face and neck has been analyzed as a local prognostic factor in many studies. Based on 4000 measurements of thermograms of 100 healthy adults, Weinstein²⁴ described the cut-off point for identifying pathologies associated with pain in the head as the absolute value of the temperature differences between corresponding homonymous structures in excess of 0.5°C. This value was determined using spot measurements. Normal  temporomandibular  joint  (TMJ)  examination  using thermography had showed symmetrical thermal patterns with a mean ΔT value of 0.1°C.²⁵ On the other hand, patients affected with internal derangement and TMJ osteoarthritis showed ΔT values of + 0.4°C.¹² Beth and Gratt in 1996 conducted a double‑blinded clinical.²⁶

Krzysztof Woźniak et al [2015], the study confirmed its limited diagnostic efficiency in identifying subjects with TMD – 95.5% specificity in identifying patients with no symptoms of dysfunctions according to Di when the absolute difference in temperature between the right and left side (ΔT) zones was lower than 0.26°C with sensitivity 44.3% and accuracy 52.4% before chewing test and 0.52°C with sensitivity 46.4% and accuracy 56.3% after test. The chewing test was a major factor that increased the efficiency of thermography in identifying patients with TMD. Further research is needed on the use of thermography in the diagnosis of TMD.⁸

In D S Hadda et al [2014], infrared imaging revealed a difference of 1.4°C between mean anterior temporalis and masseter muscle temperatures and a difference of 0.09 between the corresponding normalized temperatures in asymptomatic subjects, indicating that the temporalis was significantly more hyper-radiant than the masseter (p < 0.05). The results of sensitivity and specificity of the thermographic assessment for masticatory muscle regions suggest greater diagnostic accuracy when absolute mean temperature (×T) is used, even when translated to dimensionless temperature (×θ). These results suggest that thermal values, if used in conjunction with physical. assessment, can serve as a means of screening and improved diagnostic accuracy in myogenous TMDs.⁹

In U. Snekhalatha et al [2018]  study has shown the value of infrared thermography as a technique which can be used for obtaining additional relevant information of patients with dental disorders, both symptomatic, and asymptomatic. In this study all abnormal subjects showed elevated temperature over the affected region, which is mostly due to the in- creased muscular activity and therefore a reciprocal increase in blood supply.¹⁰

Conclusion

This systematic review has proven the demand for future clinical trials to assess diagnosis of orofacial pain by using thermography. Hence it can be concluded that from analyzing the above 6  articles which consist of both patient’s with symptomatic and asymtomatic conditions of orofacial pain, indicates a positive result in which the thermographic value or the facial temperature of patient’s with orofacial pain was found to be raised than with that of asymtomatic patient’s. Even though the results in some of the studies were positive and promising, it has certain limitations pertaining sensitivity of orofacial disorders, which was found to be low compared to that of specificity. Hence more of a long term evidence based studies should be performed pertaining the use thermography as routine diagnostic tool in orofacial disorders.

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