Papers by Andrew Pullinger
Oral surgery, oral medicine, and oral pathology, 1985
Transcranial radiographs are frequently used to assess condyle-fossa relationships. However, thei... more Transcranial radiographs are frequently used to assess condyle-fossa relationships. However, their validity in representing condyle position has been questioned. Intermethod comparisons were performed between methods assessing condyle position by subjective evaluation and by linear and area measurement of the interarticular space. Linear measurement of the subjective closest anterior and posterior interarticular space and subjective evaluation were the mutually preferred methods in both transcranial radiographs and tomograms. Statistically significant correlations were shown (p less than 0.05) for condyle position between pairs of clinical transcranial radiographs and linear tomograms of the same temporomandibular joints. However there was a qualitative concordance in assessed posterior concentric and anterior positions in only 80% of the pairs, and a full concordance in the degree of condylar displacement was found in only 60% of the cases. Although still clinically helpful, the us...
Oral surgery, oral medicine, and oral pathology, 1986
Mandibular orthopedic diagnosis is frequently based on observation of radiographic nonconcentric ... more Mandibular orthopedic diagnosis is frequently based on observation of radiographic nonconcentric condyle-fossa relationships, but the definition of normal and abnormal positions is, in part, obscured by the several different methods used to assess condyle position and the absence of intermethod comparisons. This study compared the measurement and expression of condyle position in tomograms according to subjective evaluations and linear and area measurement of the interarticular space by use of a microcomputer and graphics tablet. Area analysis showed the least concordance with the subjective evaluation. Linear measurement of the subjective closest anterior and posterior interarticular space presented the greatest concordance, had low interobserver variation, and was considered clinically relevant to the functional thickness of the center of the articular disk.
Oral surgery, oral medicine, and oral pathology, 1989
This comparative imaging study of the TMJ was conducted to examine the diagnostic data obtained f... more This comparative imaging study of the TMJ was conducted to examine the diagnostic data obtained from arthroscopy as compared to data from tomography and arthrography. Six joints from cadaver material were imaged by each technique and subsequently dissected. Each technique had value, but none was comprehensive. Tomography was the technique of choice for imaging osseous changes. Double joint space arthrotomography was useful for examining articular disk position and morphology. Diagnostic arthroscopy, through direct visualization of surface morphology, showed localized surface pathosis, such as synovitis; provided data on the location and size of disk perforations; and contributed reliably to a diagnosis of disk displacement on the basis of associated pathosis such as stretching of the posterior attachment.
Oral surgery, oral medicine, and oral pathology, 1989
New electronic thermographic instruments capable of routine clinical examination need to be evalu... more New electronic thermographic instruments capable of routine clinical examination need to be evaluated for their potential as a diagnostic aid in dentistry. This study assessed thermal symmetry of the face and neck in 20 normal subjects with the use of frontal and lateral views, at 1.0 degree C and 0.5 degree C sensitivity, under controlled conditions. Electronic thermographic images were analyzed for thermal symmetry, by means of a grid matching technique, in 12 anatomic regions and the overall face. Results indicated that thermal symmetry for the entire face was high (70.2%). The 12 specific facial areas demonstrated varying levels of thermal symmetry. Regions of high symmetry on frontal projections included the anterior portion of the neck (82.0%), the TMJ (80.0%), the lower lip (78.6%), and the upper lip (77.3%). The temporal region (46.7%) was found to be of relatively low thermal symmetry. Regions of high symmetry on lateral projections included the nasal region (69.5%) and the...
The Journal of the American Dental Association, 1989
Do patients with temporomandibular disorders (TMD) have significant psychosocial problems? Resear... more Do patients with temporomandibular disorders (TMD) have significant psychosocial problems? Research efforts have sought to determine if these problems exist, and if so, how they influence treatment outcome. Even when psychosocial factors do influence treatment outcome, identifying them by formal psychological tests can be time consuming and costly. Dentists' impressions of the psychological status of these patients were tested to determine if they are an effective method for screening psychological factors thought to influence treatment outcome. The results suggested that a screening procedure based on dentists' impressions from an initial examination do not adequately identify psychological problems in patients with TMD.
Journal of the California Dental Association, 2012
Sleep disorders affect more than 20 percent of the U.S. population, but less than 7 percent have ... more Sleep disorders affect more than 20 percent of the U.S. population, but less than 7 percent have been medically diagnosed. Dentists are ideally positioned to identify many patients who fall under the grouping of sleep-disordered breathing. This paper presents perspectives on sleep-related issues from various medical specialties with a goal to broaden the dentist's appreciation of this topic and open avenues of communication. Algorithms are proposed to guide dentists following positive screenings for sleep-disordered breathing.
Journal of Dental Sleep Medicine, 2000
Sleep and Breathing, 2012
Introduction Medical school surveys of pre-doctoral curriculum hours in the somnology, the study ... more Introduction Medical school surveys of pre-doctoral curriculum hours in the somnology, the study of sleep, and its application in sleep medicine/sleep disorders (SM) show slow progress. Limited information is available regarding dentist training. This study assessed current pre-doctoral dental education in the field of somnology with the hypothesis that increased curriculum hours are being devoted to SM but that competencies are still lacking. Materials and methods The 58 US dental schools were surveyed for curriculum offered in SM in the 2008/2009 academic year using an eight-topic, 52-item questionnaire mailed to the deans. Two new dental schools with interim accreditation had not graduated a class and were not included. Responses were received from 49 of 56 (87.5%) of the remaining schools. Results and Conclusions Results showed 75.5% of responding US dental schools reported some teaching time in SM in their pre-doctoral dental program with curriculum hours ranging from 0 to 15 h: 12 schools spent 0 h (24.5%), 26 schools 1-3 h, 5 schools 4-6 h, 3 schools 7-10 h, and 3 schools >10 h. The average number of educational hours was 3.92 h for the schools with curriculum time in SM, (2.96 across all 49 responding schools). The most frequent-ly covered topics included sleep-related breathing disorders (32 schools) and sleep bruxism (31 schools). Although 3.92 h is an improvement from the mean 2.5 h last reported, the absolute number of curriculum hours given the epidemic scope of sleep problems still appears insufficient in most schools to achieve any competency in screening for SRBD, or sufficient foundation for future involvement in treatment.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 1995
The purpose of this study was to measure the amount of new information contributed by temporomand... more The purpose of this study was to measure the amount of new information contributed by temporomandibular joint tomograms beyond that anticipated by the patient's clinical presentation. The results of a clinical examination and history, including a video of patient interview, and dental casts of 105 patients with a temporomandibular disorder were presented to a panel of general dentist evaluators with some experience in temporomandibular disorders. These evaluators then described the radiographic findings they anticipated. Lastly they examined temporomandibular joint tomograms for each of the study patients and scored their findings. The temporomandibular joint tomograms revealed unanticipated osseous changes in 61% of case judgments of condyles and 47% for the temporal bone or 34% and 22%, respectively, when subtle changes were excluded. Unexpected condyle positional findings were revealed in 31% of the patients. When stratified by clinical class, osteoarthritis and internal derangement, false-positive and false-negative interpretations were 12.1% and 25.5%, respectively, for osteoarthritis, and 12.2% and 17.3% for derangement. The fairly high rate of unexpected new osseous and positional findings supports the need for tomograms in patients with a clinical diagnosis of derangement or osteoarthritis.
The Journal of Prosthetic Dentistry, 2002
There is disagreement about the predictive value of temporomandibular joint tomographic anatomy i... more There is disagreement about the predictive value of temporomandibular joint tomographic anatomy in the diagnosis of internal derangements. This study aimed to identify multifactorial temporomandibular hard tissue relationships that differentiate disk displacement with reduction and disk displacement without reduction from normals. Temporomandibular joint tomograms from females diagnosed with unilateral disk displacement with (n=84) or without (n=78) reduction were compared to 42 asymptomatic normal joints with the use of 14 linear and angular measurements and 8 ratios. A validated classification tree model was tested for accuracy with sensitivity, specificity, goodness of fit, and the amount of log likelihood accounted for. The tree model was compared with a multiple logistic regression model and univariate testing. The disk displacement with reduction tree model consisted of 3 disease and 2 normal pathways with interactions between fossa width to depth ratio, condyle position, and linear posterior joint space. This class was characterized by either a much wider- and shallower-than-average fossa shape and/or by a moderately posterior condyle position when the fossa shape was average to deeper and/or narrower. The logistic regression and univariate models also suggested wider and/or shallower fossae, as well as longer eminence length. The disk displacement without reduction tree model consisted of 2 disease pathways and 1 normal pathway. Interactions characterized this class by either a posterior to very posterior condyle position or by a much deeper than average fossa depth when the condyle position was concentric to anterior. The logistic regression model emphasized greater fossa depth and width versus normals. The tree models conservatively predicted the disease classes: Rescaled Cox and Snell R(2) 37.0%, sensitivity 70.2%, and specificity 90.5% for disk displacement with reduction; R(2) 28.8%, sensitivity 66.7%, and specificity 85.7% for disk displacement without reduction. Within the limitations of this study, hard tissue relationships revealed by central tomogram sections were able to model notable differences between disk displacement with reduction and disk displacement without reduction versus asymptomatic normals when temporomandibular joints were examined as a multifactorial system typified by interactions of fossa width to depth proportions and condyle position. While substantial, the hard tissue predicted only part of the biology. The model could be broadened by additional factors and interactions.
The Journal of Prosthetic Dentistry, 2002
There is persistent dispute about the diagnostic value of hard tissue anatomic relationships in p... more There is persistent dispute about the diagnostic value of hard tissue anatomic relationships in predicting temporomandibular joint disorders and normals. The goal of this study was identification of multifactorial temporomandibular hard tissue relationships that differentiate asymptomatic normal joints. Central section lateral tomograms of 162 female temporomandibular joints with pooled diagnoses of unilateral disk displacement with and without reduction were compared to 42 female asymptomatic normal joints using 14 linear and angular measurements and 8 ratios. A validated classification tree model was tested for accuracy with sensitivity, specificity, goodness of fit, and the amount of the log likelihood accounted for. The tree model was compared with a multiple logistic regression model and univariate testing. The classification tree model consisted of 3 asymptomatic and 4 disk displacement terminal nodes consisting of interactions of condyle position with measures of fossa size and shape, of which mainly average non-extreme measurements and more frequent concentric ranges typified the asymptomatic joints. The logistic regression and univariate models also incorporated condyle position and size, but the logistic regression accounted for less of the log likelihood than the tree (23.3% vs. 32.6% Rescaled Cox and Snell R(2)). The tree and the logistic regression models were moderately good predictors for distinguishing normals from disk displacement joints (sensitivity 67.9% and 72.2%, specificity 85.7% and 76.2%, respectively). Although the univariate analysis showed that the asymptomatic joints had smaller mean fossa width to fossa depth ratios (P<.0005), shorter mean eminence length (P<.007), and more concentric to anterior mean condyle position (P<.049), overlap in most of the ranges limited the predictive value. Within the limitations of this study, multifactorial analysis revealed that several subsets of asymptomatic temporomandibular joints could be distinguished from joints with disk displacement according to hard tissue measurements taken from central section tomograms. In general, asymptomatic normal joints were typified by interactions of less extreme ranges of fossa size, shape, and condyle position.
The Journal of Prosthetic Dentistry, 1988
Two complete classes of freshman dental and dental hygiene students, 120 men and 102 women (mean ... more Two complete classes of freshman dental and dental hygiene students, 120 men and 102 women (mean age 23.9 years) were assessed for the presence of masticatory pain or dysfunction by questionnaire, clinical examination, and evaluation of dental casts according to strict criteria. The purpose was to identify the degree of association between observable signs of TMJ disorders and selected combinations of occlusal variables. TMJ tenderness was more frequent in class II, division 2 than in class I (p less than .05), but overall was not associated with occlusal factors such as deep overbites, length of a symmetric RCP-ICP slide, and unilateral contact in RCP. Overall, clicking was not associated with Angle class, deep overbite, length of symmetric RCP-ICP slide, or unilateral RCP contact. Among subjects with unilateral RCP contact, those with no clinically obvious RCP-ICP slide (p less than .005) and those with asymmetric slides (p less than .05) had more TMJ clicking than subjects with symmetric slides. Luxation clicking of the condyle over the articular eminence on wide opening was absent in class II, division 2 subjects, but was most frequent in subjects with some teeth in unilateral posterior crossbite, particularly when this was a unilateral condition (p less than .001). Certain occlusomorphologic conditions may require less adaptation in the TMJs. This article indicates that an ICP anterior to the RCP in association with bilateral occlusal stability may be protective.
The Journal of Prosthetic Dentistry, 1988
Two complete classes of freshman dental and dental hygiene students, 120 men and 102 women (mean ... more Two complete classes of freshman dental and dental hygiene students, 120 men and 102 women (mean age 23.9 years), were assessed for the presence of masticatory pain or dysfunction by questionnaire, clinical examination, and evaluation of dental casts. The purpose of these examinations was to determine potential relationships between clinical muscle tenderness, occlusal relationships, and signs of TMJ dysfunction. Awareness of muscle tenderness increased with the number of muscle sites involved (p less than or equal to .025) but 80% of clinically tender subjects were unaware of any tenderness (p less than or equal to .01). In comparison, subjects with generalized clinical muscle tenderness more often reported TMJ clicking that was not verified at the time of clinical examination (p less than or equal to .001). Occlusal factors, except in highly selective categories, were not associated with muscle tenderness. All subjects with moderate or severe TMJ tenderness had clinically tender muscle sites, whereas subjects with generalized muscle tenderness (greater than or equal to 4 sites) had more severe TMJ tenderness (p less than or equal to .01). Subjects with localized (p less than .05) or generalized muscle tenderness (p less than .05) had more TMJ clicking than those without muscle tenderness. TMJ clicking was reported more commonly than muscle pain among subjects who were clinically determined to have both muscle tenderness and TMJ clicking (p less than or equal to .001). TMJ dysfunction was verified more often in subjects with more localized muscle tenderness (p less than or equal to .025). Although occlusal factors were not good predictors of muscle tenderness, intracapsular signs of TMJ disorders and muscle tenderness were often associated.
The Journal of Prosthetic Dentistry, 1988
Freshman dental and dental hygiene students, 120 men and 102 women (mean age 23.9 years), were as... more Freshman dental and dental hygiene students, 120 men and 102 women (mean age 23.9 years), were assessed for the presence of masticatory pain or dysfunction by questionnaire, clinical examination, and evaluation of dental casts according to strict criteria. The purpose was to identify and analyze the level of signs and symptoms in a nonpatient population and describe occlusal variation. The prevalence of TMJ signs and symptoms was notable even though two thirds reported only mild or early symptoms, with only 3% reporting severe symptoms. This population was noted for the absence of locking, the low frequency of severe pain or severe TMJ dysfunction, and the low prevalence of restricted ranges of mandibular movement and TMJ crepitation. Women showed significantly more headache, TMJ clicking and tenderness, and muscle tenderness than men. Men were noted for the absence of severe and widespread muscle tenderness and severe TMJ tenderness. TMJ clicking was not always clinically confirmable in subjects with widespread muscle tenderness. This group was considered compatible with previous epidemiologic findings, and also matches the age range of most subjects seeking treatment for TMJ disorders. Therefore, the subjects in the study were considered a representative group of young adults and suitable for study of the possible associations between early signs of TMJ disorders and variables of morphologic malocclusion, which are discussed in Parts II and III of this article.
The Journal of Prosthetic Dentistry, 1985
The Journal of Prosthetic Dentistry, 1986
Journal of Oral Rehabilitation, 1987
According to linear interincisal measurements, women have a smaller maximum jaw opening than men.... more According to linear interincisal measurements, women have a smaller maximum jaw opening than men. In this study the difference was 2.7%. In contrast, epidemiological surveys indicate that women have a greater mobility of joints and generally more joint laxity. Covariate analysis was used to test for the difference between sexes in mean maximum passive opening adjusted according to group mean differences in other parameters of body size. The net result was that the values became more equal between sexes. A second method, employing a geometric estimation for the angle of maximum jaw opening, showed that women had a 5.4% wider range of jaw opening than men (P less than 0.057). This method avoided the problem of considering relative body size and body factors which generally correlated poorly with maximum opening. It should be noted that an increased range of opening is a measure of hyperextensibility and does not necessarily imply laxity or instability.
Community Dentistry and Oral Epidemiology, 1995
ABSTRACT
American Journal of Orthodontics and Dentofacial Orthopedics, 1987
This article investigates the influence of occlusion on condylar position as seen on TMJ tomogram... more This article investigates the influence of occlusion on condylar position as seen on TMJ tomograms in a group of 44 young adults with no histories of orthodontic or occlusal therapy and no objective signs of masticatory dysfunction; the sample was screened from a population of 253 students. Nonconcentric condylar position at ICP was a feature of Class II malocclusion with significantly more anterior positions in Class II, Division 1 than in Class I. Condylar position was unrelated to the amount of sagittal RCP-ICP slide, although most slides were less than 0.5 mm. The frequency of lateral slides was low, but was mildly related to bilaterally asymmetric condylar positions. Position was unrelated to the degree of overbite, which ranged from 0 to 10 mm. Bilateral condylar position asymmetry was not related to the direction of dental midline discrepancy, which ranged from 0 to 2 mm. No open bites or mandibular overjets were seen in this asymptomatic normal sample.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 1995
This study examined the influence of lateral and frontal temporomandibular joint tomograms on the... more This study examined the influence of lateral and frontal temporomandibular joint tomograms on the initial diagnosis and treatment plan of patients having facial or preauricular pain or temporomandibular joint disorders. Five or six general dentists, all with experience in treating patients with disorders of the temporOmandibular joint, examined records of 105 patients from a university-based orofacial pain clinic. The examiners proposed a diagnosis and treatment plan for each patient without the benefit of tomograms. They then repeated this procedure after study of the radiographs. The impact of the radiographs was measured as the change in pre- versus postradiographic diagnosis and treatment plan. The availability of temporomandibular joint tomograms changed or modified diagnosis in 65% of the judgments and influenced treatment recommendations in 40%. These changes were substantive for 21% of the diagnoses and 22% of the treatment plans. The strongest correlation to changes in both diagnosis and treatment plan was with radiographic detection of osseous changes. New information about condyle position had less effect on clinical decisions. These findings indicate that temporomandibular joint tomograms play a valuable role in influencing clinician's diagnosis and treatment plan of patients with disorders of the temporomandibular joint.
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Papers by Andrew Pullinger