Clinical Oral Investigations (2020) 24:97–102

https://doi.org/10.1007/s00784-019-02891-3

ORIGINAL ARTICLE

The outcome of a temporomandibular joint compression test

for the diagnosis of arthralgia is confounded by concurrent myalgia
Anna Lövgren 1 & Corine M. Visscher 2 & Per Alstergren 3,4,5 & Frank Lobbezoo 2 & Birgitta Häggman-Henrikson 1,3 &
Anders Wänman 1

Received: 17 December 2018 / Accepted: 2 April 2019 / Published online: 25 April 2019
# The Author(s) 2019

Abstract
Objective Pain in the orofacial region may originate from different structures, and one challenge for the clinician is to determine
the primary origin of pain reported by the patient. In clinical practice, it is important to discriminate between a temporomandib-
ular joint (TMJ) pain disorder and jaw muscle pain; therefore, tests that are proposed for such purposes warrant evaluation. The
aim of the present study was to evaluate the outcome of a TMJ compression test in relation to a Diagnostic Criteria for
Temporomandibular Disorders (DC/TMD) arthralgia diagnosis.
Methods A study population (n = 300), randomly selected from the adult population in Västerbotten, Sweden, was examined
according to the DC/TMD criteria and with a TMJ compression test. This test is comprised of forceful unilateral biting for 20 s on
a wooden spatula in the first molar region. Familiar pain on the contralateral side to the clenching side was considered a positive
test outcome.
Results Positive contralateral outcome of the TMJ compression test was associated with an arthralgia diagnosis (B = 1.737; OR
5.7, 95% CI 3.3–9.9). This association was confounded by concurrent myalgia (B = 1.737 → B = 0.996, 42.7%).
Conclusion In a general population, a negative TMJ compression test was strongly associated with the absence of a contralateral
TMJ arthralgia diagnosis according to DC/TMD. The association between a positive TMJ compression test and a DC/TMD
arthralgia diagnosis was confounded by the presence of myalgia.
Clinical relevance Concurrent myalgia renders the usefulness of the TMJ compression test for predicting an arthralgia diagnosis
questionable.

Keywords Temporomandibular disorder . Temporomandibular joint . DC/TMD . Diagnostic tests . Diagnostic accuracy

Introduction

* Anna Lövgren Temporomandibular disorders (TMD) are considered muscu-

[email protected] loskeletal disorders that embrace pain or dysfunction of the
temporomandibular joint (TMJ) and masticatory muscles [1,
1
Department of Clinical Oral Physiology, Faculty of Medicine, 2]. TMD is the most common reason for chronic pain in the
University of Umeå, 901 87 Umeå, Sweden orofacial region [3] and is commonly associated with interfer-
2
Department of Oral Kinesiology, Academic Centre for Dentistry ence in daily life [4, 5].
Amsterdam (ACTA), University of Amsterdam and Vrije The Diagnostic Criteria for Temporomandibular Disorders
Universiteit, Amsterdam, The Netherlands (DC/TMD) is a valid process to diagnose the most common
3
Department of Orofacial Pain and Jaw function, Faculty of TMD conditions. In the DC/TMD, both TMJ pain (arthralgia)
Odontology, Malmö University, Malmö, Sweden and myalgia diagnoses are based on self-reported pain modi-
4
Specialized Pain Rehabilitation, Skåne University Hospital, fied by function, in combination with familiar pain elicited
Lund, Sweden during jaw movements or palpation [6]. Both these diagnoses
5
Scandinavian Centre for Orofacial Neurosciences, Malmö, Sweden have a high diagnostic sensitivity and specificity. In the clin-

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98 Clin Oral Invest (2020) 24:97–102

ical setting, it is important to discriminate between a TMJ pain ipsilateral pain during unilateral clenching may, therefore, be
disorder and jaw muscle pain since both the etiology and the indicative for myalgia of the masticatory muscles. However,
management of these conditions may differ. A discriminating the association between myalgia and ipsilateral pain during a
diagnostic test is therefore warranted in order to recognize TMJ compression test has not been evaluated. An evaluation
arthralgia and myalgia independently. This can be of special of the TMJ compression test can thus add relevant diagnostic
clinical relevance when the arthralgia is related to arthritis. In information.
such case, anti-inflammatory pharmacological management The first aim of this study was to determine if the TMJ
may be considered as a primary treatment regimen in order compression test could predict a DC/TMD arthralgia or my-
to reduce inflammatory activity, to reduce pain, and to prevent algia diagnosis. The second aim was to determine possible
further degeneration of the cartilage and bone tissue in the confounders of such associations. Our hypothesis was that
TMJ [7]. contralateral elicited familiar pain would be predictive for a
We previously reported a substantial overlap between TMJ TMJ pain condition (arthralgia), and that an ipsilaterally elic-
arthralgia and masticatory myalgia in a validation study of ited familiar pain would be predictive for a masticatory muscle
three screening questions (3QTMD) in relation to DC/TMD pain condition (myalgia).
diagnoses [7]. These findings are in line with those reported
by Schiffman and co-workers [8]. In the clinical examination
to reach the diagnosis arthralgia, palpation of the lateral pole Materials and methods
affects also tissues outside the TMJ proper that includes mus-
cle tissue, skin, and connective tissue. Moreover, mandibular Participants
movements probably do not cause solely TMJ pain but also
muscle pain, given that the muscles are activated. The location The study population comprised 300 adult individuals (98
of pain, especially in patients with chronic pain, is an uncer- men and 202 women; mean age 38.7 years, SD 13.8).
tain indicator for its origin due to pain spreading, referred pain, Participants were randomly recruited from the Public Dental
and sensitization mechanisms [9]. Even though pain location Health Care in the county of Västerbotten, Sweden, based on
may still be relevant for an arthralgia diagnosis, the close their answers to three screening questions for TMD (3Q/
location of the lateral pterygoid and masseter muscles in rela- TMD) [15]. The 3Q/TMD is likely to be positive in the case
tion to the TMJ complicates the diagnostics. In addition, local of DC/TMD pain diagnoses and negative when DC/TMD
or generalized hyperalgesia may lead to positive signs from pain diagnoses are absent. In total, 148 screen positives and
palpation of jaw muscles and/or the TMJ and thereby affect 152 screen negatives were included in the study. The entire
the outcome of the diagnostic procedure. There is thus a need recruitment process has been previously described in detail
for evaluating diagnostic tests that are hypothesized to more [15].
precisely determine if the origin of pain is located to the mus-
cles, to the TMJ, or to both. Diagnostic criteria for temporomandibular disorders
One such diagnostic test may be a TMJ compression test diagnoses of arthralgia and myalgia
[10]. In this test, the patient bites hard on a wooden spatula
placed between the teeth in the molar region on one side in All participants underwent the standardized DC/TMD Axis I
order to physically compress intraarticular structures, espe- examination (questionnaire and clinical examination) The
cially on the contralateral side. A previous experimental study DC/TMD diagnoses Barthralgia^ and Bmyalgia^ were used
showed that biting on a rigid interference placed unilaterally in as reference standards [6]. The DC/TMD pain diagnoses are
the molar region caused a frontal, upward rotation of the man- based on self-reported pain during the last 30 days that is
dibular condyle contralateral to the interference in all subjects modified (i.e., aggravated or relieved) by jaw function.
[11]. A recent study reported that patients with unilateral TMJ During the clinical examination, an arthralgia diagnosis is
disc displacement had a higher prevalence of elicited contra- confirmed if the patient reports pain in the TMJ area during
lateral TMJ pain when biting on a bite force transducer in the the last 30 days, as confirmed by the examiner, in combination
molar region [12]. Unilateral clenching in the molar region has with familiar pain from the TMJ on jaw movements or palpa-
been shown to induce a significant reduction of the TMJ joint tion. A myalgia diagnosis is confirmed if the patient reports
space contralateral to the biting side [13]. These studies indi- pain in the masseter or temporal muscles during the last
cate that unilateral clenching in the molar region induces a 30 days in combination with familiar pain with either muscle
compression of the contralateral TMJ, and may thus elicit a palpation or maximum jaw opening. Familiar pain was de-
nociceptive response if the intraarticular tissues are sensitized. fined as Bpain that is similar or like the pain [the patient]
In addition to contralateral TMJ pain, it was also suggested may have had in that same part of your body in the last 30
that unilateral clenching can provoke ipsilateral fatigue and days^ as per the definition in the DC/TMD [6]. All examina-
pain in the masticatory muscles [14]. In clinical practice, tions were performed by a single examiner (author AL) who

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Clin Oral Invest (2020) 24:97–102 99

was calibrated [16] and was blinded as to whether the partic- Statistical analysis
ipant screened positive to the 3Q/TMD or not. The reliability
of the examiner was assessed at a DC/TMD Training and Frequencies for positive test outcomes are presented descrip-
Calibration Centre and was found to be Balmost perfect^ for tively. Since all individuals could contribute with data from
arthralgia and myalgia [17] (Cohen’s Kappa values; arthralgia two tests, sensitivity and specificity were calculated for each
right, 0.87; arthralgia left, 0.88; myalgia, 0.82). test separately. The sensitivities and specificities were there-
fore calculated for a positive contralateral compression test
TMJ compression test outcome in relation to a DC/TMD arthralgia diagnosis, and
for a positive ipsilateral compression test outcome in relation
The TMJ compression test was performed with the participant to a myalgia diagnosis, respectively. Confidence intervals for
biting as hard as possible for 20 s on a double-wooden spatula sensitivity and specificity were calculated according to the
(thickness 2 × 2 mm) in the first permanent molar region Wilson score method [21]. To account for the two measure-
(Fig. 1). The participant was allowed to refrain from or abort ments in each individual in the study sample (n = 300), the
the test if it became too uncomfortable due to, for example, association between a positive test outcome as the dependent
tooth pain. The participant was instructed to report experi- variable and the DC/TMD diagnosis as the independent vari-
ences and locations of familiar pain on the ipsilateral or con- able was established using an unstructured, binary logistic
tralateral side in the orofacial area during the test period. In generalized estimating equation (GEE).
total, 12 tests on the right side and 16 tests on the left side To evaluate if an association was confounded, the follow-
could not be performed due to missing teeth or to the test ing models were analyzed:
being too uncomfortable for the participant.
To determine if an association between a positive test out- Model I:1 TMJ compression test (contralateral side) vs.
come and an arthralgia diagnosis was confounded [18], the arthralgia
following variables were evaluated: myalgia, limited maxi- Model I:2 Model I:1 + myalgia
mum jaw opening (< 40 mm including vertical overbite), Model I:3 Model I:2 + limited jaw maximum opening
and widespread pain. The association between a positive test Model I:4 Model 1:3 + widespread pain
outcome and a myalgia diagnosis was evaluated with arthral-
gia, limited vertical maximum opening (< 40 mm including Model II:1 TMJ compression test (ipsilateral side) vs.
vertical overbite), and widespread pain as possible myalgia
confounders. Model II:2 Model 1:1 + arthralgia
Widespread pain was assessed with the use of the body Model II:3 Model II:2 + limited jaw maximum opening
drawing in the McGill Pain Questionnaire [19]. The whole Model II:4 Model II:3 + widespread pain
body was divided into 19 sites, and widespread pain was cat-
egorized as positive when pain was reported in seven or more The association between the TMJ compression test and
of these sites [20]. arthralgia or myalgia, respectively, was considered to be

Fig. 1 Biomechanical hypothesis

behind the temporomandibular
joint compression test

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100 Clin Oral Invest (2020) 24:97–102

confounded when the regression coefficient of the TMJ com- Table 2 Sensitivity and specificity for contralateral compression test in
relation to TMJ contralateral arthralgia according to the DC/TMD (TMJ
pression test changed by > 10% as compared with its value in
sides, n = 572*)
the previous model (without that confounding variable) [22].
To check for multicollinearity, all possible independent var- Arthralgia No arthralgia
iables were entered in a correlation matrix. If the correlation
TMJ compression test (contralateral) positive 0.40 (40) 0.09 (41)
coefficient between two independent variables exceeded 0.70,
TMJ compression test (contralateral) negative 0.60 (59) 0.91 (432)
multicollinearity [18], which may disrupt the model, was con-
sidered to be present. In that case, the independent variable *Missing data from 28 tests
that is the most strongly associated variable will be chosen to
enter into the binary logistic model. The statistical analyses CI 0.29–0.42) and 0.93 (95% CI 0.90–0.95), respectively
were carried out with SPSS version 24.002 and a probability (Table 3).
level of < 0.05 was considered statistically significant. The positive contralateral outcome of the TMJ compres-
The study was approved by the Regional Ethical Review sion test was associated with a contralateral arthralgia diagno-
Board at Umeå University, Sweden (reference number 2012- sis (B = 1.737; OR 5.7, 95% CI 3.3–9.9) (Table 4). This asso-
331-31M). All participants signed a written informed consent, ciation was confounded by concurrent myalgia (B = 1.737 →
prior to the data collection. As recommended for diagnostic B = 0.996, 42.7%), but not by widespread pain or limitation of
accuracy studies, the STARD statement was followed [23]. vertical jaw movements. Ipsilateral positive test outcomes
were associated with a myalgia diagnosis (B = 1.962; OR 7.1
95% CI 3.9–13.0) (Table 5). This association was confounded
by a concurrent ipsilateral arthralgia diagnosis (B = 1.962 →
Results B = 1.270, 35.2%) and widespread pain (B = 1.280 → B =
1.003, 21.6%), but not by the limitation of vertical jaw
In total, 60 participants (20% of the study population) had a movements.
positive compression test outcome on the contralateral side of
the clenching (36 on the right side, and 45 on the left TMJ
side) (Table 1). In addition, the test provoked an ipsilateral
familiar pain outcome in 68 participants (51 times on the right
Discussion
side and 49 times on the left side).
The main finding from this study is that the TMJ compression
A DC/TMD arthralgia diagnosis was established in 66 in-
test has a high specificity and it generates a high negative
dividuals (Table 1), representing 22% of the study population
predictive value for contralateral DC/TMD diagnosis of ar-
(13 men and 53 women, mean age 38.1 years; SD 15.0). Three
thralgia. This indicates that a negative TMJ compression test
individuals (1%) qualified for an arthralgia diagnosis without
is strongly associated with the absence of a contralateral TMJ
concurrent myalgia.
arthralgia diagnosis according to DC/TMD. On the other
The sensitivity and specificity for a positive outcome of the
hand, a positive outcome of the TMJ compression test is only
TMJ compression test on the contralateral side in relation to an
modestly associated with contralateral TMJ arthralgia diagno-
arthralgia diagnosis on the contralateral side were 0.40 (95%
sis. In addition, the association between the TMJ compression
CI 0.31–0.50) and 0.91 (95% CI 0.88–0.94), respectively
test and a contralateral TMJ arthralgia diagnosis is confound-
(Table 2). The sensitivity and specificity for an ipsilateral fa-
ed by the presence of myalgia. This indicates that the predic-
miliar pain in relation to a myalgia diagnosis were 0.35 (95%
tive value of the TMJ compression test for a diagnosis of
Table 1 Frequency distribution in the study sample (n = 300) contralateral TMJ arthralgia is even lower in the case of con-
current myalgia.
n (%) In clinical practice, the outcome of a diagnostic test should
preferably provide reliable and valid guidance for the selec-
DC/TMD arthralgia diagnosis 66 (22)
tion of specific treatment strategies. For any pain condition,
Unilateral right 18 (6)
Unilateral left 9 (3) Table 3 Sensitivity and specificity for ipsilateral compression test in
Bilateral 39 (13) relation to myalgia according to the DC/TMD (TMJ sides, n = 572*)
Myalgia 106 (35)
Myalgia No myalgia
TMJ compression test positive (contralateral) 60 (20)
TMJ compression test positive (ipsilateral) 68 (23) TMJ compression test (ipsilateral) positive 0.35 (73) 0.07 (27)
Limited jaw opening 13 (4) TMJ compression test (ipsilateral) negative 0.65 (133) 0.93 (339)
Widespread pain ≥ 7/19 sites 94 (31)
*Missing data from 28 tests

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Clin Oral Invest (2020) 24:97–102 101

Table 4 Binary logistic, generalized estimating equations for associations between positive compression test and contralateral DC/TMD arthralgia
expressed as regression coefficients (B), odds ratio (OR), and its 95% confidence intervals within parenthesis

Contralateral arthralgia Model 1 + myalgia Model 2 + limited vertical movement Model 3 + widespread pain
Single association

B OR B OR B OR B OR

TMJ compression test positive 1.737 5.7 (3.3–9.9) 0.996 2.7 (1.5–5.0) 0.954 2.6 (1.4–4.8) 0.880 2.4 (1.3–4.4)

early identification and intervention are important to prevent Taken together, the results suggest that the TMJ compres-
chronicity [24]. Chronic pain conditions also tend to embrace sion test is associated with the absence of TMJ arthralgia if
more complex and widespread symptoms. Therefore, in these there is a negative outcome of the test, even after the correc-
conditions, specific diagnostic strategies are required in order tion of possible confounders. Future studies should explore
to distinguish a local symptom from a widespread condition. whether the addition of the compression test to the test battery
Since TMJ pain and masticatory muscle pain may, at least in of the DC/TMD would improve the sensitivity and specificity
part, have different etiologies, there is a clinical need for a of the current DC/TMD algorithms.
diagnostic test that accurately distinguishes these conditions.
However, the findings from the present study indicate a low Methodological considerations
sensitivity, when only a minority of the individuals with TMJ
arthralgia report a positive TMJ compression test outcome. The study population was randomly selected from the Public
With regard to the potential confounding factors, myalgia Dental health care and therefore, the results may be considered
was found to influence the association between the test out- as representative for the adult populations in general, in Sweden
comes and the diagnosis of arthralgia. There may be multiple and for comparable countries. In addition, all clinical examina-
possible explanations. Firstly, the results may indicate that the tions were performed by a formally trained and calibrated ex-
DC/TMD criteria do not sufficiently discriminate myalgia aminer which accounts for high diagnostic reliability. However,
from arthralgia, which may be supported by the fact that the study was primarily developed for investigating the TMJ
95% of those with arthralgia also fulfilled the criteria for my- compression test as part of the clinical examination. As a con-
algia. Secondly, it may indicate that myalgia and arthralgia are sequence, the index test (the compression test) was not per-
in fact concurrent conditions and mirror a local, regional, or formed ahead of the reference standard test (the DC/TMD), as
generalized sensitization. The complexity of the temporoman- proposed in the STARD initiative [23]. The DC/TMD examina-
dibular region means that any diagnostic test may be ham- tion could thereby have provoked pain that is then reproduced
pered by the presence of comorbidity [25]. during the index test for this study, i.e., the TMJ compression
The ipsilateral positive test outcome also showed a moder- test. Another possible limitation is that the pain location after the
ate diagnostic precision for the detection of myalgia with low TMJ compression test was not assessed for the TMJ and
sensitivity and high specificity. In clinical practice, the ab- masseter/temporalis muscles separately. In this case, these fac-
sence of an ipsilateral positive test outcome may thus be in- tors would have caused false positive responses. However, the
dicative for the absence of myalgia. Since the association with low sensitivity contradicts this possible shortcoming.
myalgia was not only confounded by a concurrent arthralgia
but also by widespread pain, this may indicate that myalgia Conclusion
could be related to general hyperalgesia rather than to local
factors [26]. This finding indicates that general pain condi- In a general population, a negative TMJ compression test was
tions may be incorrectly interpreted as a local TMD pain strongly associated with the absence of a contralateral TMJ
condition. arthralgia diagnosis according to DC/TMD. The association

Table 5 Binary logistic, generalized estimating equations for associations between ipsilateral TMJ compression positive test outcome, and myalgia
expressed as regression coefficients (B), odds ratio (OR), and its 95% confidence intervals within parenthesis

Myalgia Model 1 + arthralgia Model 2 + limited vertical movement Model 3 + widespread pain
single association

B OR B OR B OR B OR

TMJ compression test positive 1.962 7.1 (3.9–13.0) 1.270 3.6 (1.8–7.0) 1.276 3.6 (1.8–7.1) 1.003 2.7 (1.3–5.7)

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102 Clin Oral Invest (2020) 24:97–102

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between Umeå University and Västerbotten County Council in coopera- 11. Rassouli NM, Christensen LV (1995) Experimental occlusal inter-
tion with the field of Medicine, Odontology and Health and the Swedish ferences. Part III. Mandibular rotations induced by a rigid interfer-
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Ipsilateral molar clenching induces less pain and discomfort than
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tional and/or national research committee and with the 1964 Helsinki 14. Sforza C, Zanotti G, Mantovani E, Ferrario VF (2007) Fatigue in
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creativecommons.org/licenses/by/4.0/), which permits unrestricted use, tions (3Q/TMD) in relation to the DC/TMD. J Oral Rehabil 43(10):
distribution, and reproduction in any medium, provided you give appro- 729–736. https://doi.org/10.1111/joor.12428
priate credit to the original author(s) and the source, provide a link to the 16. Vilanova LS, Garcia RC, List T, Alstergren P (2015) Diagnostic
Creative Commons license, and indicate if changes were made. criteria for temporomandibular disorders: self-instruction or formal
training and calibration? J Headache Pain 16:505. https://doi.org/
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