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UNIVERSIDADE FEDERAL DE GOIÁS
FACULDADE DE ODONTOLOGIA
PÓS-GRADUAÇÃO EM ODONTOLOGIA
MODALIDADE ARTIGO CIENTÍFICO
EFICÁCIA DE DIAGNÓSTICO DA TOMOGRAFIA
COMPUTADORIZADA E RESSONÂNCIA MAGNÉTICA NO
TRATAMENTO DAS DESORDENS DA ARTICULAÇÃO
TEMPOROMANDIBULAR: UMA REVISÃO SISTEMÁTICA
Dissertação de Mestrado
ALUNA: Karlla Dias Siqueira Marques
ORIENTADORA: Profa. Dra. Rejane Faria Ribeiro-Rotta
GOIÂNIA
2009
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UNIVERSIDADE FEDERAL DE GOIÁS
FACULDADE DE ODONTOLOGIA
PÓS-GRADUAÇÃO EM ODONTOLOGIA
MODALIDADE ARTIGO CIENTÍFICO
EFICÁCIA DE DIAGNÓSTICO DA TOMOGRAFIA
COMPUTADORIZADA E RESSONÂNCIA MAGNÉTICA NO
TRATAMENTO DAS DESORDENS DA ARTICULAÇÃO
TEMPOROMANDIBULAR: UMA REVISÃO SISTEMÁTICA
Dissertação de mestrado apresentada ao Programa de
Pós-Graduação em Odontologia da Universidade
Federal de Goiás para obtenção do Título de Mestre
em Odontologia.
ALUNA: Karlla Dias Siqueira Marques
ORIENTADORA: Profa. Dra. Rejane Faria Ribeiro-Rotta
GOIÂNIA
2009
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BANCA EXAMINADORA DA DEFESA DE MESTRADO
Aluna: Karlla Dias Siqueira Marques
Orientadora: Profa. Dra. Rejane Faria Ribeiro-Rotta
Membros:
1. Rejane Faria Ribeiro-Rotta
2.
Paulo César Rodrigues Conti
3.
Cláudio de Góis Nery
Suplente:
Sicknan Soares da Rocha
Curso de Pós-Graduação em Odontologia da
Universidade Federal de G
o
i
ás
Data: 22 de abril de 2009
Dedico este trabalho:
Aos meus pais, João Dias e Maria de Lourdes, pelo exemplo, amor, dedicação e incentivo
de toda uma vida.
Às minhas irmãs, Luanna e Kássia, pela amizade e carinho.
A meu esposo, Fabiano, pela dedicação, amor e companheirismo.
AGRADECIMENTOS:
A todos aqueles cujos esforços possibilitaram a conclusão deste trabalho.
À Dra. Rejane Faria Ribeiro-Rotta; pela sabedoria, confiança e paciência com que me
conduziu. E principalmente pelo companheirismo e zelo nesta etapa final.
Ao Dr. Cláudio Rodrigues Leles, pela inestimável contribuição no desenvolvimento
deste trabalho.
À colega graduanda Mayra Jubé Pacheco, pela amizade, dedicação e contribuição
direta para realização deste trabalho.
Aos colegas de mestrado Luciana, Cintia, Gláucia, Paula, Fabiana, Luciano, Eduardo,
Érika, Francine, Cláudia pela amizade e companheirismo nesta caminhada em busca do
conhecimento.
A todos os professores desta casa, cuja sabedoria no ensinar foi fundamental no
desenvolvimento da minha capacidade de pensar e buscar o conhecimento científico.
Aos colegas e funcionários do Centro Goiano de Doenças da Boca, em especial, Claudia
Duarte que, com grande competência, desempenha seu trabalho.
À Universidade Federal de Goiás, pelo suporte técnico e apoio financeiro necessário à
realização da pesquisa.
À minha família, pelo incentivo e exemplo.
E principalmente a Deus, por orientar meus caminhos, ampliar meus horizontes e por me
conduzir com sabedoria e benevolência nos desafios e conquistas da minha vida.
Sumário
SIGLAS E ABREVIATURAS
RESUMO
ABSTRACT
1
CARACTERIZAÇÃO DO PROBLEMA
10
2
JUSTIFICATIVA / OBJETIVO
15
3
MATERIAL E MÉTODOS
17
4
RESULTADOS E PUBLICAÇÃO
26
5
CONCLUSÕES / CONSIDERAÇÕES FINAIS
64
6
REFERÊNCIAS BIBLIOGRÁFICAS
65
7
APÊNDICES
81
7
Siglas e abreviaturas
AAOMR American Academy of Oral and Maxillofacial Radiology
(Academia Americana de Radiologia Oral e Maxilofacial)
ATM Articulação Temporomandibular
CBCT Cone Bean Computed Tomography (Tomografia
Computadorizada por Feixe Cônico)
CDC TMD Clinical Diagnostic Criteria Temporomandibular Disorders
(Critério de Diagnóstico Clínico para as Desordens
Temporomandibulares)
CT Computed tomography ( Tomografia Computadorizada)
DATM Desordens da Articulação Temporomandibular
DTM Desordem Temporomandibular
FLASH MRI Fast Low Angle Shot Magnetic Resonance Imaging (Imagens
de Ressonância Magnética)
MESH TERMS Medical Subject Headings Terms (Termos Indexadores
Padronizados da Base de Dados PubMed)
MRI Magnetic Resonance Imaging (Imagem por Ressonância
Magnética)
QUADAS Quality Assessment of Diagnostic Accuracy Studies (Avaliação
da Qualidade dos Estudos sobre Acurácia de Diagnóstico)
RDC / TMD Research Diagnostic Criteria for Temporomandibular Disorders
(Critérios de Diagnóstico para Pesquisa das Desordens
Temporomandibulares)
RM Ressonância Magnética
ROC Receiver Operating Characteristic Curves (Curva de
Operadores e Receptores de Características)
TC Tomografia Computadorizada
TMD TemporomandibularDisorders (Desordem Temporomandibular)
TMJ Temporomandibular Joint (Articulação Temporomandibular)
TMJD Temporomandibular Joint Disorders (Desordens da Articulação
Temporomandibular)
Resumo
O diagnóstico das desordens que afetam a articulação temporomandibular (ATM) tem sido
uma tarefa difícil por inúmeras razões que incluem: a complexidade estrutural e funcional
desta articulação, a origem multifatorial dessas desordens e o conhecimento limitado sobre a
evolução natural das mesmas, presença de sintomas comuns entre as suas várias subclasses
e em outros comprometimentos craniofaciais. Se a premissa do tratamento efetivo é o
diagnóstico correto, fica claro que o tratamento dessas desordens não é menos complexo
que o diagnóstico das mesmas. O objetivo deste estudo foi analisar sistematicamente a
literatura sobre a evidência da eficácia terapêutica da tomografia computadorizada (TC) e
ressonância magnética (RM) no plano de tratamento das desordens da ATM (DATM)
(deslocamento do disco, desordens inflamatórias sem envolvimento sistêmico e
osteoartrose). A realização desta revisão sistemática constituiu-se de 3 etapas: (1)
especificação do problema e dos critérios de inclusão e exclusão das publicações; (2)
formulação e detalhamento do plano de busca na literatura; (3) interpretação e integração
das evidências dos estudos e formulação das recomendações baseada na qualidade das
evidências. A busca bibliográfica foi realizada nas bases de dados PubMed e Biblioteca
Cochrane no período de janeiro de 1966 a julho de 2009, utilizando-se de termos específicos
indexados, selecionados de acordo com os objetivos. Os títulos e resumos assim
encontrados foram analisados por três examinadores e as publicações que preencheram os
critérios de inclusão foram selecionadas. Os mesmos três examinadores fizeram a leitura
integral das publicações selecionadas e dados foram extraídos com o auxílio de um
protocolo previamente elaborado. A publicação foi considerada relevante e incluída na
revisão, quando seus resultados expressavam algum tipo de impacto das informações
obtidas com TC e RM no tratamento do deslocamento do disco, desordens inflamatórias
locais e osteoartrose – eficácia terapêutica. Essas publicações relevantes foram interpretadas
utilizando-se de um instrumento de análise da qualidade da publicação, desenvolvido
especificamente para estudos que investigam métodos de diagnóstico – QUADAS – Quality
Assessment of Diagnostic Accuracy Studies. A busca na literatura resultou em 584 títulos e
resumos, dos quais 257 foram selecionados e lidos na íntegra. Somente 1 estudo foi
considerado relevante. Este estudo avaliou a eficácia da RM no diagnóstico da posição,
configuração e perfuração do disco, na efusão articular e nas alterações ósseas e medulares
da ATM, mas nenhuma publicação reportou sobre eficácia dos achados de diagnóstico ou
eficácia terapêutica. A ausência de estudos sobre a eficácia terapêutica da RM e TC nas
DATM reforça a necessidade de investimentos em estudos sobre tomada de decisões,
entretanto, exames de imagem seccionais devem ser prescritos com precaução,
especialmente quando os orçamentos em saúde são limitados.
9
Abstract
Diagnosis of disorders affecting the temporomandibular joint (TMJ) is a difficult task for
many reasons. These include the structural and functional complexity of this joint, the
multifactorial origin of these disorders and limited knowledge of their natural course, the
presence of common symptoms among its various subclasses and other craniofacial
conditions. If the premise for effective treatment is a correct diagnosis, it is clear that the
treatment of these disorders is not any less complex than their diagnosis. The aim of this
study was to do a systematic analysis of the literature in relation to proof of the therapeutic
efficacy of computed tomography (CT) and magnetic resonance imaging (MRI) in the
treatment planning of TMJDs (disc displacement, inflammatory disorders without systemic
involvement or osteoarthosis). This systematic review was comprised of three steps: (1)
Specifying the problem and the inclusion/exclusion criteria used in the publications; (2)
Formulation and detailing of a plan to conduct the literature search; (3) Interpretation and
integration of the evidence in the studies and formulation of recommendations based on the
quality of the evidence. The bibliographical search was undertaken in PubMed and
Cochrane Library databases from January 1966 to July 2009, using specific indexed terms,
selected according to the objectives. The titles and abstracts found were analyzed by three
examiners and the publications fulfilling the inclusion criteria were selected. The same three
examiners read the full texts of these selected publications, and extracted data with the help
of a previously drawn up protocol. A publication was considered relevant and included in
the review when its results expressed any type of impact of the information obtained with
CT and MRI on the treatment of disc displacement, local inflammatory disorders or
osteoarthosis – therapeutic efficacy. Publications considered relevant were interpreted with
the aid of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool and
publications that critically evaluate systematic reviews. Results: The literature search
yielded 584 titles and abstracts, of which 257 were selected and read in full text. One study
was judged relevant. This study evaluated evidence of the efficacy of magnetic resonance
imaging (MRI) in the diagnosis of disc position and configuration, disc perforation, joint
effusion, and osseous and bone marrow changes in the temporomandibular joint, but no
publication reported diagnostic thinking efficacy or therapeutic efficacy. The absence of
studies on the therapeutic efficacy of CT and MRI on TMJD reinforces the need for
investment in decision-making studies; meanwhile, sectional imaging tests should be
prescribed with caution, especially when health budgets are limited…………………………
10
1. Caracterização do problema
Desordem temporomandibular (DTM) é um termo genérico que abrange vários
problemas clínicos, com muitos sinais e sintomas semelhantes envolvendo a musculatura da
mastigação e/ou a articulação temporomandibular (ATM) e estruturas associadas (OKESON,
1996). Essas desordens se caracterizam por dores nos músculos da mastigação, área pré-
auricular e/ou ATM sendo usualmente agravada pela função; limitação dos movimentos
mandibulares e/ou alterações na trajetória de abertura e fechamento bucal; ruídos articulares
descritos como estalido ou crepitação. Cansaço ou fadiga muscular, dores na maxila e
mandíbula, dor de ouvido, dor de cabeça e na região facial são comuns (DWORKIN &
LERESCHE, 1992; MCNEILL, 1993; OKESON, 1996). As dores de origem neurogênica,
psicogênica, muco-cutânea, visceral (ex: dentária, glândulas salivares) ou musculoesquelética
(periodontal) devem ser incluídas no diagnóstico diferencial das DTM (OKESON, 1996).
A dor orofacial não odontogênica que mais frequentemente leva a população a
procurar o dentista ou outros profissionais de saúde é aquela associada à DTM
(DONALDSON & KROENING, 1980). Mais de 75% da população adulta tem pelo menos
um sinal de DTM e aproximadamente 30% tem mais de um sinal. Porém somente 3 a 7% da
população que procura avaliação e orientação realmente necessitam de tratamento. (ADLAM
APUD KLIPPEL & DIEPPE, 1998). Apesar de frequente, várias lacunas do conhecimento
ainda não foram esclarecidas pela ciência a respeito da etiologia, diagnóstico e tratamento
das DTM em suas diversas manifestações (DWORKIN & MASSOTH, 1994; MCNEILL
1997a). A multiplicidade e falta de padronização da nomenclatura, taxionomia e critérios de
diagnóstico (DWORKIN & LERESCHE 1992; VELASCO et al., 2005); a origem
multifatorial dessas desordens com a sobreposição de sinais e sintomas (DWORKIN &
LERESCHE, 1992; MCNEILL, 1993; OKESON, 1996; MCNEILL, 1997a; MCNEILL,
11
1997b; EMSHOFF et al., 2003; BARBOSA et al., 2008) bem como o conhecimento
deficiente sobre o seu curso natural, são alguns dos principais fatores determinantes da
complexidade do diagnóstico das DTM na rotina clinica.
Até meados do século XX, os fatores etiológicos atribuídos a então chamada
Síndrome da Disfunção da ATM eram relacionados apenas ao sistema mastigatório e não
articulares (DWORKIN & LERESCHE 1992; MCNEILL, 1997a). Farrar (1972) reorientou a
pesquisa nessa área, dando ênfase às desordens intra-articulares da ATM como causa da
disfunção, classificando-as em oito categorias taxonômicas de diagnóstico, de acordo com a
caracterização clínica das mesmas. Desde então, vários outros critérios diagnósticos e
taxionômicos têm sido propostos com o objetivo de facilitar e padronizar o diagnóstico
clínico: Block (1980); Eversole e Machado (1985); Bell (1986); Fricton (1988); American
Academy of Craniomandibular Disorders (AACD) (1990); American Academy of Head,
Neck, Facial Pain and TMJ Orthopedics (1990); International College of Cranio-mandibular
Orthopedics (ICCMO) (1990); Truelove (1992); Dworkin and Leresche (1992); Okeson
(1996); Japanese Society for the Temporomandibular Joint (JSTMJ) (2001) ( DWORKIN,
LERESCHE 1992). Dentre esses, Truelove (1992) foi o primeiro a contemplar critérios
diagnósticos definidos para cada categoria clínica, diferenciando as alterações musculares
(mialgia e dor miofascial), alterações intra-articulares (deslocamento de disco com ou sem
redução, capsulite / sinovite e perfuração de disco), e desordens ósseo-degenerativas. No
mesmo ano, Dworkin e Leresche (1992) propuseram critérios de diagnósticos para pesquisa
das DTM (Research Diagnostic Criteria for Temporomandibular Disorders - RDC / DTM),
com o objetivo de favorecer a padronização e a reprodutibilidade das pesquisas sobre essas
desordens, colocando-as sob bases mais racionais e científicas.
Em alguns subgrupos das DTM, as técnicas de exame por imagem são incluídas
como auxiliares do diagnóstico, principalmente quando o exame clínico sugere
12
comprometimento articular (MCNEILL, 1997b). O objetivo da imagem da ATM é avaliar a
integridade das estruturas quando desordens são suspeitas, confirmar o estágio e progressão
da doença e avaliar o efeito do tratamento (BROOKS et al., 1997). No entanto, a decisão de
prescrever um exame por imagem deve considerar os achados e o diagnóstico clínicos e,
ainda, a contribuição deles no diagnóstico final e plano de tratamento do paciente, suas
vantagens e desvantagens enquanto técnica selecionada, o seu custo e a exposição do
paciente a radiação (BROOKS et al., 1997). Dentre os vários métodos de imagens, as
técnicas seccionais têm papel de destaque, sendo que as mais utilizadas como exames
complementares incluem a tomografia computadorizada (TC) e a ressonância magnética
(RM). A TC tem sido referida como um dos melhores métodos para avaliar a ATM quando a
suspeita clínica relaciona-se aos tecidos ósseos e as imagens por RM quando o foco da
investigação são as partes moles (BROOKS, et al. 1997; RIBEIRO, 1996). Estudos têm
sido realizados no sentido de se verificar a relação entre os achados clínicos e as informações
dos exames por imagem. Estudos apontam a acurácia dos exames por imagens seccionais no
diagnóstico das variadas DATM (HARMS, 1987; RAO, 1993; WARNKE, 1996;
SUENAGA, 1996), porém há pouca evidência sobre a eficácia terapêutica dos mesmos.
Uma visão limitada a respeito dos objetivos do diagnóstico por imagens é aquela que
considera ser esses métodos os fornecedores das melhores imagens e dos diagnósticos mais
acurados. Sob uma análise mais ampla, o diagnóstico por imagem é parte de um grande
sistema cujo objetivo é tratar o paciente de forma efetiva e eficiente. Para o entendimento
ampliado de eficácia, é necessário considerar padrões que vão além da qualidade e acurácia
dos exames por imagem.
Fryback e Thornbury (1991) descreveram um modelo hierárquico de eficácia do
diagnóstico por imagem com seis níveis: nível 1 = diz respeito à qualidade técnica da
imagem; nível 2 = aborda acurácia de diagnóstico, sensibilidade e especificidade associadas
13
com a interpretação da imagem; nível 3 = avalia se a informação gerada pela imagem
modifica o diagnóstico clínico estabelecido; nível 4 = avalia a eficácia no plano de
tratamento do paciente; nível 5 = mede ou computa o impacto das informações do exame no
resultado do tratamento do paciente; nível 6 = avalia o custo-benefício da tecnologia de
diagnóstico por imagem para a sociedade. A característica de destaque deste modelo é o
entendimento de que, para um exame por imagem atingir o nível mais alto de eficácia, ele
deve ser eficaz nos níveis mais inferiores; o inverso não é verdadeiro. A eficácia em um nível
inferior (ex. qualidade técnica da imagem), não garantirá melhoria proporcional em níveis
mais elevados (ex. resultado do tratamento do paciente). As pesquisas que avaliam eficácia
dos métodos de diagnóstico por imagem, frequentemente, consideram apenas os níveis 1 e 2
(FRYBACK & THORNBURY, 1991). Diante de todas as controvérsias em torno das DATM
torna-se notória a importância da busca de evidências científicas da eficácia dos referidos
métodos em níveis mais superiores.
Evidência é o objeto do conhecimento que não comporta nenhuma dúvida quanto a
sua verdade ou falsidade (FERREIRA, 1999). Evidência científica é o conjunto de
elementos que apóiam a confirmação ou a negação de uma determinada teoria ou hipótese
científica. Dentre os diferentes tipos de estudos, a revisão sistemática está situada no topo da
pirâmide da qualidade do desenho de estudo quando o objetivo é a busca de evidências
científicas para tomadas de decisões clínicas. Ela difere das revisões de literatura tradicionais
(narrativas) por empregar um maior rigor metodológico na busca, seleção, avaliação e síntese
de estudos, com uma metodologia amplamente documentada e passível de reprodução
(LELES & FREIRE, 2005).
Um criterioso exame clínico e classificação das DATM, baseados em critérios de
classificação já validados, assim como a prescrição de exames por imagem que realmente
somem ao plano de tratamento são pré-requisitos essenciais não apenas para o sucesso do
14
tratamento, mas para o estabelecimento do custo-benefício de todas as etapas, desde o
diagnóstico ao acompanhamento do paciente, bem como a determinação de um impacto
sócio-econômico mais equilibrado para a sociedade.
15
2. Justificativa / Objetivo
Tomando-se como base:
1. A alta prevalência e incidência das DATM (DONALDSON, 1980; ADLAM apud
KLIPPEL, 1998; EGERMARK, 2001; MAUTONI, 2007 ).
2. As lacunas do conhecimento a respeito do diagnóstico e tratamento das DATM em suas
diversas manifestações (DWORKIN & MASSOTH 1994; OKESON, 1996; MCNEILL
1997a; DWORKIN & LERESCHE 1992; VELASCO et al., 2005).
3. Que a primeira etapa no efetivo tratamento das DATM é um diagnóstico acurado.
4. Que ainda existe controvérsias sobre: se o exame clínico é suficiente para demonstrar a
verdadeira condição da ATM (MARGUELLES-BONNET, 1995; LARHEIM, 2005).
5. Que o principal objetivo dos exames por imagem deveria ser a contribuição para o
tratamento adequado do paciente (FRYBACK & THORNBURY, 1991).
6. As vantagens e desvantagens da TC e RM enquanto técnicas selecionadas para o estudo
das DATM (BROOKS et al., 1997; LINCHAICHANA, 2006).
7. A controvérsia na literatura quanto ao real benefício dos exames por imagens seccionais
no diagnóstico e tratamento das desordens da ATM (LINCHAICHANA, 2006).
Este estudo tem como objetivo:
Verificar a evidência da eficácia dos achados diagnósticos e/ou eficácia terapêutica da TC e
RM no plano de tratamento das DATM – deslocamentos do disco articular, desordens
inflamatórias e osteoartrose.
16
Hipótese:
Não há evidências da eficácia terapêutica da TC e RM no plano de tratamento das DATM.
Se existir, estará relacionada com o tratamento das DATM em estágios crônicos avançados
(osteoartrose) e/ou inflamatórios agudos.
17
3. Material e métodos
A abordagem sistemática da literatura utilizada neste estudo seguiu as recomendações
de Goodman (1996), compostas por 7 etapas: (1) especificação do problema, (2)
especificação dos critérios de inclusão e exclusão das publicações, (3) formulação do plano
de busca na literatura, (4) detalhamento do plano de busca e execução do mesmo, (5)
interpretação da evidência dos estudos individualmente, (6) integração das evidências, (7)
formulação das recomendações baseada na qualidade das evidências.
3.1. Especificação do problema / Critérios de inclusão e exclusão das publicações
Para a especificação do problema, a seguinte pergunta foi estabelecida: Qual o
impacto das informações obtidas pelas imagens por TC e/ou RM no diagnóstico final e
decisão terapêutica do paciente com DATM?
Os termos que nortearam a estratégia de busca na literatura foram estabelecidos
segundo a definição dos subtítulos médicos do PubMed (MeSh terms – Medical Subject
Headings):
Temporomandibular joint disorders: uma variedade de condições que afetam
as características anatômicas e funcionais da articulação temporomandibular.
Os fatores que contribuem para a complexidade das DATM são: sua relação
com a dentição e a mastigação, os efeitos sintomáticos em outras áreas, o que
soma para a dor referida na ATM e para as dificuldades em aplicar
procedimentos diagnósticos tradicionais nas afecções da ATM, cujos tecidos
raramente são visualizados, e os raios-X são frequentemente inadequados ou
inespecíficos. As doenças mais comuns são: alterações do desenvolvimento,
18
trauma, subluxação, luxação, artrites e neoplasias.
Temporomandibular Joint: é a articulação entre a cabeça da mandíbula e o
tubérculo articular do osso temporal.
Tomography, X-Ray computed: tomografia que utiliza emissão de raio-X e
um algoritmo de computador para reconstrução da imagem.
Magnetic resonance imaging: método não invasivo de demonstrar a anatomia
do interior do corpo, baseada no princípio de que os núcleos atômicos sob um
intenso campo magnético absorvem pulsos de energia de radiofreqüência e,
reemitem essa energia na forma de ondas de radio, as quais podem ser
reconstruídas em imagens computadorizadas. O conceito inclui técnicas
tomográficas de spin protônico.
Na busca de respostas para a pergunta estabelecida, considerou-se a palavra impacto
relativa às informações fornecidas pela TC e RM, sinônimo de eficácia de diagnóstico
(diagnostic accuracy-efficacy), eficácia de diagnóstico clínico (diagnostic thinking efficacy),
eficácia terapêutica (therapeutic efficacy) ou qualquer combinação das anteriores, como
descrito por Fryback e Thornbury (1991), para o diagnóstico das desordens de deslocamento
do disco, desordens inflamatórias sem envolvimento sistêmico (capsulite e sinovite) e
osteoartrose da ATM.
Apenas as publicações na língua inglesa que possuíam resumo disponível, realizadas
em seres humanos adultos e indexadas nas bases de dados no período de 1º
de janeiro de
1966 a 31 de julho de 2009, foram incluídas. Publicações sobre outras lesões na ATM como
traumas, neoplasias, doenças sistêmicas, condromatose sinovial, estudos realizados em
cadáver, publicações do tipo revisão da literatura narrativa, relato de caso e avaliação
específica de outros exames por imagem da ATM como as artrografias, artrotomografia,
artroscopia, ultrassonografia e cintigrafia, que não incluíssem TC e RM, foram excluídas da
19
amostra. As revisões da literatura narrativa, apesar de excluídas da amostra, foram
selecionadas para a realização da busca manual por títulos de interesse, nas suas listas de
referências.
A eficácia de diagnóstico foi definida de acordo com adaptação do modelo
hierárquico descrito por Fryback e Thornbury (1991):
Eficácia técnica (nível 1) – quando os resultados foram apresentados na
forma de:
- Resolução de pares de linhas
- Alterações na modulação de transferência de função
- Variação da escala de cinzas
- Matizes
- Nitidez
- Parâmetros de aquisição de imagem
Acurácia-eficácia de diagnóstico (nível 2) - quando os resultados foram
apresentados na forma de:
- Concordância entre observadores expressa como concordância global, índice
Kappa ou coeficiente de correlação
- Número de diagnóstico anormais e normais em uma série de casos
- Acurácia de diagnóstico como porcentagem de diagnósticos corretos em uma
série de casos
- Sensibilidade, especificidade ou valores preditivos positivos/negativos em
um conjunto de problemas clínicos definidos
- Medidas de altura ou da área sob a curva ROC (Receiver Operating
Characteristic Curve)
Eficácia de diagnóstico clínico (nível 3) - quando os resultados foram
20
apresentados na forma de:
- Número (porcentagem) de casos em uma série, nos quais imagens foram
julgadas “úteis” para o diagnóstico
- Mudança na distribuição das probabilidades de diagnóstico diferencial
- Diferença na estimativa subjetiva das probabilidades de diagnóstico pelos
profissionais antes e depois da informação fornecida pelo do método em teste
- Razão empírica subjetiva log-probabilidade para testes positivo e negativo
em uma série de casos
Eficácia terapêutica (nível 4) - quando os resultados foram apresentados na
forma de:
- Número (porcentagem) de vezes em que a imagem foi julgada útil no
planejamento do tratamento do paciente em uma série de casos
- Porcentagem de vezes que um procedimento médico foi evitado com base na
informação da imagem.
- Número ou porcentagem de vezes em que a terapia pré-teste mudou depois
que a informação de imagem foi obtida (inferido retrospectivamente dos
registros clínicos)
- Número ou porcentagem de vezes em que o profissional mudou sua escolha
terapêutica depois da informação do exame
3.2. Formulação e detalhamento do plano de busca na literatura
O primeiro passo foi utilizar termos indexados no MeSH para a busca eletrônica na
base de dados do PubMed e Biblioteca Cochrane. As buscas foram limitadas por critérios de
inclusão (Tabelas 1 e 2). A decisão de selecionar a publicação foi estabelecida pela leitura
21
de todos os títulos e resumos, realizada por três examinadores. Quando um resumo foi
considerado importante por pelo menos 1 dos examinadores, a publicação foi selecionada
para leitura do seu texto integral (Figura 1).
O segundo passo foi a leitura na íntegra, pelos três examinadores, das publicações
selecionadas, com auxílio de um protocolo previamente elaborado (JAESCHKE et al.
1994a; JAESCHKE et al., 1994b, FRYBACK & THORNBURY 1991) (Apêndice 1). As
publicações que apresentaram os critérios de inclusão foram consideradas relevantes e
incluídas no estudo. Antes de ser aplicado independentemente por cada examinador, o
Protocolo 1 foi testado em 10 publicações, de forma consensual entre os 3 examinadores.
O terceiro passo foi a busca manual na lista de referências das publicações que foram
consideradas relevantes na segunda etapa e das publicações de revisão do tema. Títulos
contendo as palavras: computed tomography, CT, cone-beam computed tomography,
CBCT, magnetic resonance imaging, MR ou MRI, TMJ radiographs associadas ao termo
temporomandibular joint, ou temporomandibular joint disorders, ou disc displacement, ou
osteoarthrosis, ou inflammatory disorders, synovitis ou capsulitis foram selecionados.
Capítulos de livros e revisões da literatura tradicionais foram excluídos, porque a busca teve
como foco publicações baseadas em estudos originais. Para os títulos/resumos inéditos que
foram considerados relevantes por pelo menos um dos examinadores, a publicação foi lida
na íntegra, e dados extraídos (Apêndice 1). Os mesmos critérios de inclusão e exclusão da
busca eletrônica foram utilizados na busca manual (Figura 1).
3.3. Interpretação/Integração das evidências dos estudos.
Aquelas publicações consideradas relevantes foram selecionadas e interpretadas
utilizando-se de um instrumento de análise da qualidade da publicação – Protocolo 2
22
(Apêndice 2) – o qual foi desenvolvido com base em instrumento construído
especificamente para estudos que investigam a eficácia de diagnóstico - QUADAS –
Quality Assessment of Diagnostic Accuracy Studies (WHITING et al., 2003; WHITING et
al, 2005a; WHITING et al., 2005b) e com base na literatura que analisa criticamente as
revisões sistemáticas(FLORES-MIR et al., 2006).
O QUADAS (WHITINING et al., 2003) não inclui escores, os quais frequentemente
são utilizados nas revisões sistemáticas para a avaliação dos níveis de evidência e conclusão
científica. Apenas os resultados de componentes chaves da avaliação foram descritos.
23
Tabela 1. Estratégia de busca realizada na base de dados PubMed
Critérios de inclusão: (1) período de: 1 Janeiro 1966 a 31 de Julho de 2009; (2) publicações indexadas com resumo, em inglês e realizadas
em humanos.
IT EM
BUSCA
#1
"TEMPOROMANDIBULAR JOINT"[MESH]
#2
TEMPOROMANDIBULAR JOINT
#3
1 OR 2
#4
"TEMPOROMANDIBULAR JOINT DISORDERS"[MESH]
#5
TEMPOROMANDIBULAR JOINT DISORDERS
#6
4 OR 5
#7
3 OR 6
#8
“ TOMOGRAPHY, X-RAY COMPUTED"[MESH]
#9
TOMOGRAPHY, X-RAY COMPUTED
#10
8 OR 9
#11
“ MAGNETIC RESONANCE IMAGING"[MESH]
#12
MAGNETIC RESONANCE IMAGING
#13
11 OR 12
#14
7 AND 10
#15
7 AND 13
#16
“REVIEW "[PUBLICATION TYPE]
#17
14 NOT 16
#18
15 NOT 17
#19
“ W OUNDS AND INJURIES"[MESH]
#20
17 NOT 19
#21
18 NOT 19
#22
“NEOPLASMS"[MESH]
#23
20 NOT 22
#24
21 NOT 22
#25
“ A RTHROSCOPY"[MESH]
#26
23 NOT 25
#27
24 NOT 25
#28
“ A RTHROGRAPHY"[MESH]
#29
26 NOT 28
#30
27 NOT 28
#31
“ULTRASONOGRAPHY"[MESH]
#32
29 NOT 31
#33
30 NOT 31
#34
“CADAVER"[MESH]
#35
32 NOT 34
#36
33 NOT 34
#37
#35 +#36)
T OTAL
#37 – PUBLICAÇÕES REPETIDAS
24
Tabela 2 – Estratégia de busca realizada na Biblioteca Chocrane
Critérios de inclusão: (1) periodo de 1 janeiro 1966 a 31 de julho de 2009
ITEM
BUSCA
#1
MESH DESCRIPTOR TEMPOROMANDIBULAR JOINT, THIS TERM ONLY
#2
TEMPOROMANDIBULAR JOINT, FROM 1966 TO 2009
#3
(#1 OR #2)
#4
MESH DESCRIPTOR TEMPOROMANDIBULAR JOINT DISORDERS, THIS TERM ONLY
#5
TEMPOROMANDIBULAR JOINT DISORDERS, FROM 1966 TO 2009
#6
(#4 OR #5)
#7
MESH DESCRIPTOR TOMOGRAPHY, X-RAY COMPUTED, THIS TERM ONLY
#8
TOMOGRAPHY X-RAY COMPUTED, FROM 1966 TO 2009
#9
(#7 OR #8)
#10
MESH DESCRIPTOR MAGNETIC RESONANCE IMAGING, THIS TERM ONLY
#11
MAGNETIC RESONANCE IMAGING, FROM 1966 TO 2009
#12
(#10 OR #11)
#13
(#3 OR #6)
#14
(#13 AND #9)
#15
(#13 AND #12)
#16
MESH DESCRIPTOR WOUNDS AND INJURIES EXPLODE ALL TREES
#17
(#14 AND NOT 16)
#18
(#15 AND NOT #16)
#19
MESH DESCRIPTOR NEOPLASMS EXPLODE ALL TREES
#20
(#17 AND NOT #19)
#21
(#18 AND NOT #19)
#22
MESH DESCRIPTOR ARTHROSCOPY EXPLODE ALL TREES
#23
(#20 AND NOT #22)
#24
(#21 AND NOT #22)
#25
MESH DESCRIPTOR ARTHROGRAPHY EXPLODE ALL TREES
#26
(#23 AND NOT #25)
#27
(#24 AND NOT #25)
#28
MESH DESCRIPTOR ULTRASONOGRAPHY EXPLODE ALL TREES
#29
(#26 AND NOT #28)
#30
(#27 AND NOT #28)
#31
MESH DESCRIPTOR CADAVER EXPLODE ALL TREES
#32
(#29 AND NOT #31)
#33
(#30 AND NOT #31)
#34
#32 + #33
TOTAL
#34 – PUBLICAÇÕES REPETIDAS
25
Figura 1 - Fluxograma com estratégia realizada na revisão sistemática com a quantidade de
resumos e publicações obtidos em cada etapa.
8 revisões
narrativas
1
Busca no PubMed
551 resumos
1 publicação selecionada
(revisão sistemática)
Busca na Livraria Cochrane
5 resumos
229 publicações
selecionadas
1 publicação
relevante
0 publicações
relevantes
Lista de referências
Lista de referências
9 Resumos
19 resumos
1. Todos os resumos foram lidos
por 3 examinadores. A seleção
das publicações foi feita de
acordo com os critérios de
inclusão e exclusão.
2. Publicações selecionadas
foram lidas na íntegra por 3
examinadores e dados foram
extraídos de acordo com
protocolo previamente elaborado.
(Apêndice 1)
3. Na lista de referências das
revisões e dos estudos incluídos,
foi realizada a busca manual de
possíveis estudos relevantes
adicionais. Então, os resumos
foram lidos para seleção dos
possíveis estudos relevantes como
na etapa 1.
4. Os estudos relevantes foram
lidos na íntegra e a qualidade das
publicações foram avaliadas.
2
3
3
1
1
0 publicações
relevantes
0 publicação
relevante
0 publicações
relevantes
1 publicação
relevante
19 publicações
selecionadas
0 publicações
selecionadas
1 publicação
relevante
4
26
4. Resultados / Publicação
Os resultados encontram-se detalhados e discutidos no artigo. Considerando-se o
grande de número de publicações excluídas, por não apresentarem critérios de inclusão na
amostra, o que inviabiliza a descrição das mesmas na publicação, a lista dessas publicações
encontra-se nos Apêndices da dissertação para os que se interessarem (Apêndice 3).
PUBLICAÇÃO:
Título:
Do computed tomography and magnetic resonance imaging add to temporomandibular
joint disorder treatment? A systematic review of diagnostic efficacy
Formatação da publicação seguindo as normas da revista International Journal of
Prosthodontics
27
Do computed tomography and magnetic resonance imaging add to temporomandibular
joint disorder treatment? A systematic review of diagnostic efficacy
Karlla Dias Siqueira Marques, DDS; Mayra Jubé Pacheco; Cláudio Rodrigues Leles, DDS, MS,
and Rejane Faria Ribeiro-Rotta DDS, MS, PhD.
Karlla Dias Siqueira Marques, DDS
Graduate student, School of Dentistry, Federal University of Goiás, Goiânia, Brazil
Address: Rua Desembargador Mario Caiado, qd 2 lt. 10, Criméia Leste, Goiânia – GO, 74660-
310 Brazil
Phone number: +55 62 3203-1705
E-mail: [email protected]
Mayra Jubé Pacheco
Undergraduate student, School of Dentistry, Federal University of Goiás, Goiânia, Brazil
Address: Rua Javaes, qd 8 lt. 1, Setor Universitário, Goiânia – GO, 74660-310 Brazil
Phone number: +55 62 3261-0128
E-mail: [email protected]
Claudio Rodrigues Leles, DDS, MS
Associate Professor, Department of Prevention and Rehabilitation Oral, School of Dentistry,
Federal University of Goiás, Goiânia, Brazil
Address: Setor Universitário, Goiânia – GO, 74280-130 Brazil
Fax/Phone: +55 62 3209-6067
E-mail: [email protected]
28
Corresponding author:
Rejane Faria Ribeiro-Rotta, DDS, MS, PhD
Associate Professor, Department of Oral Medicine, School of Dentistry, Federal University of
Goiás, Goiânia, Brazil
Address: Rua C-235 n. 1323 apt. 1501, Nova Suíça, Goiânia – GO, 74280-130 Brazil
Fax/Phone: +55 62 3209-6067
E-mail: [email protected]
ACKNOWLEDGMENT
Funded by CNPq, Ministry of Science and Technology, Brazil.
29
Do computed tomography and magnetic resonance imaging add to temporomandibular
joint disorder treatment? A systematic review of diagnostic efficacy
Abstract
Statement of problem: A question frequently asked in the clinical practice of the professional
who treats temporomandibular joint disorders (TMJD) is: “In order to make the cost/benefit ratio
worthwhile for the patient, when should I request a temporomandibular joint (TMJ) computed
tomography (CT) or magnetic resonance imaging (MRI)?” Purpose: To evaluate the evidence of
the efficacy of CT and MRI in the diagnosis of disc displacement, local inflammatory disorders,
and arthrosis of the TMJ at therapeutic efficacy level. Material and methods: PubMed and
Cochrane literature searches with specific indexing terms and a hand search were made. From
the retrieved titles and abstracts, three examiners selected publications on the basis of
predetermined inclusion and exclusion criteria. Data were extracted from the selected
publications using a previously established protocol. Publications considered relevant were
interpreted with the aid of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)
tool and publications that critically evaluate systematic reviews. Results: The literature search
yielded 584 titles and abstracts, of which 257 were selected and read in full text. One study was
judged relevant. This study evaluated evidence of the efficacy of magnetic resonance imaging
(MRI) in the diagnosis of disc position and configuration, disc perforation, joint effusion, and
osseous and bone marrow changes in the temporomandibular joint, but no publication reported
diagnostic thinking efficacy or therapeutic efficacy. Conclusions: The absence of studies on the
therapeutic efficacy of MRI and CT on TMJD reinforces the need for investment in decision-
making studies, meanwhile, sectional imaging tests should be prescribed with caution, especially
when health budgets are limited.
Keywords: Efficacy, temporomandibular joint disorders, computed tomography, magnetic
resonance imaging, review
30
Introduction
Diagnosis and treatment planning are controversial issues when focusing on patients with
temporomandibular disorders (TMD). This controversy exists for many reasons including limited
knowledge in relation to the etiology and natural history or course of TMD and the broad range
of musculoskeletal, inflammatory, and dental disorders that can be manifested as TMD,
presenting similar signs and symptoms.
1,2
Consequently, the first step in the effective treatment
of TMD is an accurate diagnosis.
The primary assessment of TMD is usually based on a clinical examination. Several
classifications of TMD have been presented: from an emphasis on internal joint derangements as
cause of the dysfunction
3
to neurological and orthopedic models of pain and dysfunction;
4
from
the integration of TMD within the larger framework of face, head, and neck pain
5
through
distinguishing between muscle alterations, internal joint alterations, and degenerative disorders
to the standardization of examination methods
6
which gather relevant data and make it possible
to compare findings and replication of research. However, several studies have demonstrated that
clinical diagnoses are unreliable as regards the status of the temporomandibular joint (TMJ).
7,8
Dworkin and LeResche
6
considered that imaging methods should be included in the diagnosis of
disc displacement without reduction, osteoarthritis, or osteoarthrosis.
Several imaging modalities have been used to assess TMJ with the aim of adding
information to the clinical findings. In broad terms, the goal of TMJ imaging is the same as in
any other region of the body, namely, to evaluate the integrity of the structures when disease is
suspected, to stage and confirm the extent and progression of a known disease, or to evaluate the
effects of treatment.
9
To achieve these goals, an assessment of the TMJ should involve both the
hard and the soft tissues. The imaging prescription decision should be made after considering the
history and clinical findings, clinical diagnosis, cost of the examination, amount of radiation
exposure, and results of prior examinations as well as the tentative treatment plan and expected
outcome. In a more global context, an imaging method should be part of a larger system where
31
*Disc displacement: a condition in which the articular disc is displaced from normal position between the condyle and the eminence to an anterior and medial
or lateral position. It can reduce on full opening, usually resulting in a noise (disc displacement with reduction) or the posterior band of the disc can remain
clearly anterior to the 12:00 position on full opening, which may or may not be associated with limited mandibular opening (disc displacement without
reduction)
.2
* Capsulitis: inflammation of the joint capsule.
2, 20
* Synovitis: inflammation in the synovial lining of the TMJ. Previously used terms: discitis, retrodiscitis.
20
* Osteoarthrosis: degenerative disorder of the joint in which the joint form and structure are abnormal.
2
therapeutic efficacy (the value of imaging methods for supporting clinicians in their diagnoses
and treatment decisions) is of interest.
10
Guidelines for radiograph prescription on the diagnosis, treatment planning, and follow-
up care of TMJ disorders (TMJD)
9,11,12
have recommended sectional images for the diagnosis of
the most prevalent TMJD, in which disc displacement, osteoarthrosis, and inflammation can be
highlighted.
13–15
Conventional and computed tomography can accomplish the diagnosis of hard
tissue changes; MRI should be considered when there is a particular need for imaging of the soft
tissues.
9,11,12
Internal derangements/disc displacements are more common in symptomatic patients,
16
with high reported prevalence in asymptomatic volunteers.
17
Disc displacement is one of the
main reasons for TMJ MRI requests, even though its diagnosis is not predictive of treatment
need. Osteoarthrosis/degenerative joint disease and inflammatory disorders/effusion are also
common TMJDs and the question of whether these disorders may be linked to the onset,
progress, or cessation of TMJ-related signs and symptoms remains a point of controversy, as
does their taxonomy and clinical classification.
18,19
These are also part of what makes clinical
decisions difficult in TMJD and the value of the imaging method for supporting clinicians in
their diagnoses and treatment decisions.
This systematic review evaluated the evidence for the diagnostic thinking efficacy and
therapeutic efficacy of CT and MRI in TMJD: disc displacement, inflammatory disorders
(capsulitis, synovitis), and osteoarthrosis.* ............................................................................
32
Material and Methods
A systematic review was developed following established guidelines.
21
The methodology
included: (1) specification of the problem and inclusion and exclusion criteria; (2) formulation of
a plan to conduct the literature search with specified indexing terms and retrieve publications;
and (3) data extraction and interpretation of the evidence from the literature retrieved.
Specification of the problem and inclusion and exclusion criteria
A question often present in the routine of the professional who treats TMJD is: “When should I
request a TMJ CT or MRI?” Based on this common clinical impasse, the following question was
drawn up to specify the problem: What is the impact of the information obtained from MR and
CT TMJ images on the TMJD final diagnosis and patient management?
The following elements were defined on the basis of medical subheadings (MeSH) prior
to the formal literature search:
Temporomandibular joint disorders: A variety of conditions affecting the anatomic
and functional characteristics of the temporomandibular joint;
Temporomandibular joint: An articulation between the condyle of the mandible and
the articular tubercle of the temporal bone;
Magnetic resonance imaging: A non-invasive method of demonstrating internal
anatomy based on the principle that atomic nuclei in a strong magnetic field absorb
pulses of radiofrequency energy and emit them as radiowaves which can be
reconstructed into computerized images. The concept includes proton spin
tomographic techniques;
Tomography, x-ray computed: Tomography using x-ray transmission and a computer
algorithm to reconstruct the image.
To be included in this systematic review the publication had to elucidate the diagnostic
thinking efficacy and/or therapeutic efficacy of MRI and/or CT in the diagnosis of disc
33
displacement, inflammatory disorders (capsulitis, synovitis), and osteoarthrosis of the TMJ. Only
publications in English conducted on human tissues were included. The exclusion criteria were
publications related to other injuries in TMJ such as trauma, tumors, systemic diseases, synovial
chondromatosis; cadaver studies; narrative literature reviews; and studies of other TMJ imaging
methods such as arthrography, arthrotomography, arthroscopy, ultrasonography and
scintigraphy, which do not include MRI or CT examinations.
Fryback and Thornbury
10
described the efficacy of an imaging technique in a hierarchical
model containing six levels of efficacy: technical efficacy (level 1); diagnostic accuracy efficacy
(level 2); diagnostic thinking efficacy (level 3); therapeutic efficacy (level 4); patient outcome
efficacy (level 5); and societal efficacy (level 6). This study focused on searching for studies that
presented diagnostic thinking efficacy and therapeutic efficacy as described below:
Diagnostic thinking efficacy:
10
Number (percentage) of cases in a series in which the image was judged "helpful" in
making the diagnosis;
Entropy change in differential diagnosis probability distribution;
Difference in clinicians’ subjectively estimated diagnosis probabilities between pre-
and post-test information;
Empirical subjective log-likelihood ratio for test positive and negative in a case series.
Therapeutic efficacy:
10
Number/percentage of times the image was judged helpful in the planning management
of the patient in a case series;
Percentage of times a medical procedure was avoided due to image information;
Number/percentage of times planned pretest therapy changed after the image information
was obtained;
Number/percentage of times clinicians’ prospectively stated therapeutic choices changed
after test information.
34
Formulation of a plan, literature search, and retrieval
The first step in the search was to use MeSH terms to search the electronic database PubMed
(Table 1) and the Cochrane Library (Table 2). The searches were limited to publications with
abstracts and entrez dates in the period from January 1, 1966 to July 31, 2009. The decision to
include a publication was made by reading the title and the abstract. Three examiners read all
abstracts. When an abstract was considered relevant by at least one examiner, the publication
was ordered and read in full text, and the data were extracted.
The second step was to hand-search the reference lists of the studies that had been
considered relevant in the first step (Figure 1). The reference lists of review articles were also
hand-searched. Titles containing the terms “computed tomography”, “CT”, “cone-beam
computed tomography”, “CBCT”, “magnetic resonance imaging”, “MR” or “MRI”, or “TMJ
radiographs” together with the terms “temporomandibular joint”, “temporomandibular joint
disorders”, “disc displacement”, “osteoarthrosis”, “inflammatory disorders”, “capsulitis”, or
“synovitis” were investigated. Inclusion and exclusion criteria were also considered in the hand
search. The abstracts of the selected references were ordered. When an abstract was considered
relevant by at least one examiner, the publication of the full text was ordered. Book chapters and
narrative literature reviews were excluded.
Data extraction and interpretation of the evidence from the literature retrieved
Data were extracted with the aid of a protocol (Appendix 1) designed on the basis of the
inclusion criteria and literature about the critical appraisal of studies on diagnostic
methods.
10,22,23
To evaluate publication quality, the studies that met the inclusion criteria were interpreted
according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool
24
and
publications that critically evaluate systematic reviews.
25
These tools
24,25
do not include quality
scores, which are frequently used in systematic reviews to assess levels of evidence and
35
scientific conclusions. The result of key components of the assessment was reported.
Results
Systematic literature search/description of studies
The number of publications retrieved, read, and interpreted is presented in Figure 1. The PubMed
searches resulted in 551 abstracts. Of these, 237 publications were selected and read in full and
their data were extracted according to the pre-established protocol (Appendix 1). No original
studies were considered relevant out of the 237 publications. The Cochrane searches resulted in
15 abstracts (Table 2) of which 5 were new and 10 had already been included in PubMed
searches. Only one publication was selected to be read in full, and data were extracted according
to the pre-established protocol (Appendix 1). This publication was a systematic review and was
considered relevant as an original study.
The second step of the search – the hand search of the reference list of the one relevant
original study and eight narrative literature reviews – resulted in an additional 28 abstracts.
After these abstracts had been read, 19 publications were selected, ordered, and read in full, and
their data were extracted. But none were considered relevant for the study (Figure 1).
Of all 257 publications selected, it was not possible to access five
26–30
in full text, and
only one
31
met the inclusion criteria. The reasons for the exclusion of the 251 publications are
presented in Tables 4 and 5. Sixty-seven excluded publications evaluated the diagnostic efficacy
of CT and MRI on TMJD, but not at the level of diagnostic thinking or therapeutic efficacy
(Table 4).
32–98
Diagnostic efficacy
Out of the 67 excluded publications
32–98
that had evaluated the diagnostic efficacy of CT and
MRI on TMJD but not at the diagnostic thinking and therapeutic level, the majority evaluated
diagnostic accuracy efficacy (n = 62) and were MRI studies (n = 54) in which the results were
36
described in terms of accuracy, yielding abnormal or normal diagnoses in case series, or
evaluating the sensitivity and specificity of the diagnostic methods and observer performance
expressed as overall agreement, kappa index, or correlation coefficients
(Table 4).
The excluded publications that had not evaluated the diagnostic efficacy of CT and MRI
in TMJD are listed in Table 5.
The only study considered relevant and included in this review was a systematic review
which had the aim of evaluating the evidence for the efficacy of MRI in the diagnosis of disc
position and configuration, disc perforation, joint effusion, and osseous and bone marrow
changes in the TMJ. In this study no publication reported diagnostic thinking efficacy or
therapeutic efficacy.
31
Its quality evaluation is presented in Table 6, together with a quality self-
evaluation of this study.
From all publications selected (n = 257) for full text reading, only 47 used diagnostic
criteria to establish the clinical diagnoses of the patient samples.
42–44,59,63,66–67,71,78,79,81–84,89,90,92,99–
127
Out of these 47 studies, seventeen
79,81–84,89,90,92,99–105
used RDC/TMD
2
, eleven
42,59,66,106–112,127
listed the criteria but did not refer to any validated criteria or TMD study, fourteen
43,44,63,71,112–121
used criteria from other published TMD studies, and six
67,68,122–125
used the Helkimo Index.
128
Among the efficacy studies (Table 4), seventeen used diagnostic criteria,
42–44,59,63,66–68,71,79,81–
84,89,90,92
eight
79,81–84,89–90,92
RDC/TMD
2
, three
42,59,66
listed the criteria in the publication but did
not refer to any validated criteria or TMD published study, four
43,44,63,71
used criteria from
previously published TMD studies, and two
67–68
used the Helkimo Index.
128
After RDC/TMD
2
,
the Helkimo Index
128
was the most frequently used diagnostic criterion in the publications
retrieved and selected for this systematic review.
Discussion
Methodological approach
To identify and evaluate available scientific evidence with regard to a particular objective, which
37
is the aim of a systematic review, a study should use valid methodological criteria. The
methodological standards used in this review were based on criteria that have been
recommended and used for many years in the evaluation of diagnostic methods.
10,21–23
It is therefore essential that individual studies included in a systematic review be
interpreted in terms of their potential for bias, lack of applicability, and quality of reporting. To
guarantee an adequate interpretation of the studies included in a diagnostic efficacy systematic
review, clear aims, elucidation of the diagnostic efficacy definition, well-established inclusion
and exclusion criteria, and an appropriate search strategy should be part of the review
methods.
129
In this study, all the mentioned aspects were accomplished, including the selection
and adaptation of an evidence-based quality assessment tool
24,25
to evaluate the quality of the
relevant publication.
Imaging diagnostic efficacy assessment
Generically, efficacy is defined as the probability of benefit to individuals in a defined
population from a medical technology applied for a given medical problem under ideal
conditions of use. The various approaches to assessing efficacy along a cognitive process can be
placed in a framework as was described by Fryback and Thornbury in 1999
10
in a hierarchical
model of efficacy. This hierarchy, which is divided into six levels, extends from basic laws of
physics (level 1), through practical clinical use, to more general patient outcome and societal
issues (level 6). Demonstration of efficacy at each lower level in this hierarchy is logically
necessary, but not sufficient, to ensure efficacy at higher levels.
The literature contains a vast number of studies of the diagnostic accuracy of TMJD CT
and MRI, but is deficient in studies that compute the effect of the information on patient
outcomes (therapeutic efficacy – level 5). The present systematic review showed that the
majority of the publications that had evaluated the efficacy (58/68) of those sectional imaging
methods were on MRI,
31,33–36,45–97
especially those in which the results were described in terms
38
of accuracy (22),
37–39,45–48,50–52,55,57,62,63,66,67,69,74–76,85,89
yielding abnormal or normal diagnoses in
case series (17),
40,41,43–44,49,53,54,56,58,59,64,68,83,84,86,91,94
and evaluating observer performance
expressed as overall agreement, kappa index, or correlation coefficients (14),
61,65,71,77–
82,87,88,92,93,95
or, in other words, levels 1 (technical efficacy) and 2 (diagnostic accuracy efficacy)
as described by Fryback and Thornbury.
10
From the 256 excluded publications, two reported therapeutic efficacy from other
imaging methods on TMJD.
127,130
Epstein et
al.
130
investigated whether the use of bone
scintigraphy as an additional aid in the diagnosis of patients with TMJ tenderness altered the
treatment or prognosis of patients. In this study, bone scan results led to changes in diagnosis
and/or treatment in 60% of the patients, and the authors concluded that bone scintigraphy may be
valuable in assessing the progress of TMJ inflammation or remodeling, and may affect the
diagnosis and treatment of patients with TMJ tenderness. White et al.
127
examined the influence
of lateral and frontal TMJ tomograms on the initial diagnosis and treatment plans of patients with
facial or preauricular pain or TMJD – derangement, osteoarthritis, or myalgia. The authors found
that TMJ tomograms changed or modified the 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 only publication which was considered relevant at level 4 – therapeutic efficacy – in
the present study was also a systematic review.
31
Since a systematic review attempts to bring the
same level of rigor to reviewing research evidence as should be used in producing that research
evidence in the first place, its inclusion as a primary study is justified. This publication
31
revealed a well-designed methodology, with clear criteria for inclusion/exclusion and search
strategy, despite language restrictions having been applied and the search strategy having been
performed in only one database, which may have excluded some articles from the sample. In the
quality assessment of primary studies the authors incorporated an overall quality score for each
included publication. Whiting et al.
129
showed that using different methods of weighting
39
individual items from the same quality assessment tool can produce different quality scores.
Incorporating these quality scores into the results of a review can lead to different conclusions
regarding the effect of study quality on estimates of diagnostic accuracy. Instead of using quality
scores as a summary indicator of quality in the results of systematic reviews, it has been
recommended that either the results of the whole quality assessment or key components of it
should be reported.
129
Similarly to our results (67/257), Limchaichana et al. (22/110)
31
found just
a few publications that have assessed diagnostic efficacy from low to moderate levels of
evidence. In their results no publication reported diagnostic thinking or therapeutic efficacy and
the authors concluded that it was impossible to draw any conclusion about when the results of
the MRI examination will result in a better treatment outcome for the TMD patients.
Systematic reviews carried out as early as 1996 have suggested that an analysis of the
impact of the imaging methods on patient treatment should be performed.
131
On the other hand,
Koh et al. found no clear evidence of a relationship between a clinical diagnosis and an MRI
diagnosis, and consistency concerning a relationship between clinical findings and MRI findings
was limited.
132
This shows the need for well-designed studies for analysis of higher levels of
efficacy and the correlation of clinical findings and MR findings. In this study we were careful to
assess which studies that evaluated the efficacy of CT and MRI had used clinical criteria for the
diagnosis, and found that of the 67 studies
32–98
, only 17 used diagnostic criteria.
42–44,59,63,66–
68,71,79,81–84,89,90,92
and less than a half of them (8/17)
79,81–84,89–90,92
used validated criteria
(RDC/TMD).
2
Clinical examination and an imaging technique are frequently applied together to
diagnose TMJD, although the evidence of the benefits of the information obtained from MR and
CT TMJ images on the TMJD final diagnosis and patient management was low. In terms of
recommending criteria for ordering TMJ radiographs, the scarcity of studies on the therapeutic
efficacy of MRI in TMJD and the absence of such studies for CT found in this study do not
support the concept that these exams are indicated in the diagnosis of TMJD when a
40
symptomatic patient seeks treatment.
Conclusions
There is a demand for improvements in the assessment of diagnostic technology and the first
steps have been taken to reach this goal. These include the development of specific tools to
evaluate the quality of diagnostic test studies, an increase in systematic review publications
showing the methodological weaknesses of studies, and publication of checklists to improve
reporting of diagnostic methods. Overall, there is a considerable need for investment in clinical
decision-making studies, and studies about the therapeutic efficacy of CT and MRI in TMJD are
no exception. Based on the results of this study, in dentistry, continuous research should be
directed to the real benefit to the patient of diagnostic methods. Meanwhile, sectional imaging
tests should be prescribed with caution, especially when there are budget restrictions.
41
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54
Legends
Table 1 – Search strategies and number of publications retrieved from PubMed.
Table 2 – Search strategies and number of publications retrieved from Cochrane Library.
Table 3 – Protocol based on the QUADAS tool (comprising questions from the original tool and
from the initial list rated using the Delphi procedure)
24
and additional questions from
publications that critically evaluate systematic reviews.
25,130
Table 4 – Excluded publications that had evaluated the diagnostic efficacy of CT and MRI in
TMJD but not at therapeutic level.
Table 5 – Excluded publications that had not evaluated the diagnostic efficacy of CT and MRI in
TMJD (the full reference list is available from the corresponding author).
Table 6 – Quality evaluation of included publication and self-evaluation of the present study.
Figure 1 – Flowchart of the selection strategy used in the systematic review and publications
remaining at each stage.
Appendix 1 – Protocol for the interpretation of the retrieved publications.
55
Table 1
Item
Indexing terms
Number
retrieved
#1
“Temporomandibular Joint” [MeSH]
3262
#2
Temporomandibular Joint
7523
#3
#1 OR #2
7523
#4
“Temporomandibular Joint Disorders” [MeSH]
5394
#5
Temporomandibular Joint Disorders
5638
#6
#4 OR #5
5638
#7
#3 OR #6
7523
#8
“Tomography, X-Ray Computed” [MeSH]
122249
#9
Tomography, X-Ray Computed
124143
#10
#8 OR #9
124143
#11
“Magnetic Resonance Imaging” [Mesh]
131178
#12
Magnetic Resonance Imaging
149115
#13
#11 OR #12
149115
#14
#7 AND #10
480
#15
#7 AND #13
831
#16
“Review” [Publication Type]
708638
#17
#14 NOT #16
428
#18
#15 NOT #17
762
#19
“Wounds and Injuries” [MeSH]
207386
#20
#17 NOT #19
313
#21
#18 NOT #19
369
#22
“Neoplasms” [MeSH]
2061331
#23
#20 NOT #22
269
#24
#21 NOT #22
544
#25
“Arthroscopy” [MeSH]
11815
#26
#23 NOT #25
263
#27
#24 NOT #25
332
#28
“Arthrography” [MeSH]
3550
#29
#26 NOT #28
250
#30
#27 NOT #28
322
#31
“Ultrasonography” [MeSH]
192980
#32
#29 NOT #31
249
#33
#30 NOT #31
318
#34
“Cadaver” [MeSH]
30012
#35
#32 NOT #34
243
#36
#33 NOT #34
317
#37
(#35 +#36)
560
Total number
of abstracts
(#37 – REPEATED ABSTRACTS) – NO
ABSTRACT TITLES
551
Inclusion criteria: Entrez date January 1, 1966 to July 31, 2009; publications indexed as “item with abstract”, “English”, and
“human.”
56
Table 2
Item
Indexing terms
Number
retrieved
#1
MeSH descriptor Temporomandibular Joint, this term only
76
#2
Temporomandibular Joint, from 1966 to 2009
499
#3
(#1 OR #2)
499
#4
MeSH descriptor Temporomandibular Joint Disorders, this term
only
211
#5
temporomandibular joint disorders, from 1966 to 2009
327
#6
(#4 OR #5)
327
#7
MeSH descriptor Tomography, X-Ray Computed, this term only
2119
#8
tomography x-ray computed, from 1966 to 2009
2361
#9
(#7 OR #8)
2361
#10
MeSH descriptor Magnetic Resonance Imaging, this term only
2789
#11
magnetic resonance imaging, from 1966 to 2009
4318
#12
(#10 OR #11)
4318
#13
(#3 OR #6)
499
#14
(#13 AND #9)
7
#15
(#13 AND #12)
37
#16
MeSH descriptor Wounds and Injuries explode all trees
10633
#17
(#14 AND NOT 16)
7
#18
(#15 AND NOT #16)
22
#19
MeSH descriptor Neoplasms explode all trees
35666
#20
(#17 AND NOT #19)
7
#21
(#18 AND NOT #19)
22
#22
MeSH descriptor Arthroscopy explode all trees
741
#23
(#20 AND NOT #22)
7
#24
(#21 AND NOT #22)
21
#25
MeSH descriptor Arthrography explode all trees
135
#26
(#23 AND NOT #25)
6
#27
(#24 AND NOT #25)
20
#28
MeSH descriptor Ultrasonography explode all trees
5336
#29
(#26 AND NOT #28)
6
#30
(#27 AND NOT #28)
20
#31
MeSH descriptor Cadaver explode all trees
444
#32
(#29 AND NOT #31)
6
#33
(#30 AND NOT #31)
20
#34
#32 + #33
26
Total number
of abstracts
(#34 –REPEATED ABSTRACTS) – NO ABSTRACT
TITLES
15
Inclusion criteria: Entrez date January 1, 1966 to July 31, 2009; publications indexed as “item with abstract”, “English”, and
“human”.
57
Table 3
First author:………...……………………...........................................……….. Article n
o
………………….………..
Yes
No
Unclear
1. Were the study objectives clearly reported?
24
x
2. Was a clear and reproducible inclusion/exclusion criterion provided?
25
x
3. Were all languages included?
25
x
4. Were included articles selected by two or more reviewers?
25
x
5. Were all electronic search terms presented in a clear and reproducible
manner?
25
x
6. Was the way in which the terms were combined presented in a clear and
reproducible manner?
25
x
7. Was an appropriate search strategy performed?
24
x
8. Were electronic searches performed in at least two databases?
25
x
9. Were the database names and date ranges searched documented?
25
x
10. Were electronic searches followed up with secondary searches?
25
x
11. Was the setting of the study relevant?
24
x
12. Were reasons for drop-out from the study reported?
24
x
13. Were tools used to assess the quality of primary studies?
129
x
14. Was the tool used to assess the quality of primary studies developed
systematically and on the basis of evidence to be used in systematic
reviews of studies on diagnostic accuracy?
129
x
15. Do the findings and conclusions answer the original question?
129
x
59
Figure 1
3
1
PubMed search
551 abstracts
1 selected publication
(systematic review)
Cochrane Library search
5 abstracts
229 selected
publications
1 relevant
publication
8 narrative
reviews
0 relevant
publications
Reference lists
Reference list
9 abstracts
19 abstracts
0 relevant
publications
0 relevant
publications
0 relevant
publications
1 relevant
publication
Stages of the selection
strategy
1. All abstracts were read by
the three examiners. A
selection of publications
was made according to
inclusion and exclusion
criteria.
2. Selected publications were
read in full text by the
three examiners and data
were extracted using the
protocol defined in
Appendix 1.
3. Reference lists of reviews
and relevant studies were
hand-searched to find
additional relevant studies.
Then, abstracts were read
to select relevant studies as
in step 1.
4. The original study was
read in full text and the
quality of the publication
was evaluated.
The original studies were read in full-
text using the QUADAS tool. (Table 2).
2
3
1
1
19 selected
publications
0 selected
publications
1 relevant
publication
4
2
60
Table 4
LEVELS OF EFFICACY
PUBLICATIONS
Level 1
(Technical efficacy
= technical quality of the
images)
CT (1)
MRI (4)
• Warnke T, 1996
32
Masui T, 1996
33
Takebayashi S, 1997
34
Honda E, 2001
35
Mazza D, 2005
36
Level 2
(Diagnostic accuracy
efficacy
= diagnostic accuracy,
sensitivity, and specificity
associated with the
interpretation of the
images)
CT (8)
MRI (54)
Helms CA, 1982
37
Helms CA, 1983
38
Helms CA, 1984
39
Larheim TA, 1984
40
Katzberg RW, 1985
41
Kircos LT, 1988
42
Karabouta I, 1990
43
Yamada K, 2003
44
Harms SE, 1985
45
Katzberg RW, 1986
46
Wilk RM, 1986
47
Harms SE, 1987
48
Kircos LT, 1987
49
Krasnow AZ, 1987
50
Schellas, KP, 1988
51
Kerstens HCJ, 1989
52
Schellhas KP, 1989a
53
Schellhas KP, 1989b
54
Rao VM, 1990a
55
Rao VM, 1990b
56
Jahn JA, 1991
57
Westesson PL,1991
58
Lieberman JM,1992
59
Brady AP, 1993
60
Moses JJ, 1993
61
Santler, G, 1993
62
Shehab AF, 1993
63
Landes C A, 2006
64
Rao VM, 1993
65
Watt-Smith S, 1993
66
Chu SA, 1995
67
Katzberg RW, 1996
68
Ren, Y, 1996
69
Suenaga S, 1996
70
Orsini MG, 1997
71
Yamada I, 1997
72
Orsini, MG, 1998
73
Suenaga S, 1998
74
Takaku S, 1998
75
Larheim TA, 1999
76
Nebbe B, 2000
77
Nueber -Moritz M, 1995
78
Emshoff R, 2001
79
Franco AA, 2002
80
Emshoff R, 2002
81
Brandlmaier I, 2003
82
Emshoff R, 2003a
83
Emshoff R, 2003b
84
Okano Y, 2003
85
Peterová V, 2004
86
Schmitter M, 2004
87
Takano Y, 2004
88
Tognini F, 2004
89
Benbelaïd R, 2006
90
Montagnani G, 2005
91
Schmitter M, 2005a
92
Aidar LA, 2006
93
Bernhardt O, 2007
94
Wang EY, 2007
95
Brooks S, 1993
96
Westerman ST, 1991
97
Limchaichana N, 2007
98
61
Table 5
REASONS FOR
EXCLUSION (n=184)
PUBLICATIONS
Studies in cadaver
specimens (11)
1. Burnett KR, 1987
2. Cavalcanti MG, 1999
Christiansen EL. 1986
Drace JE, 1990
Hansson LG, 1989
Quemar JC, 1989
Steenks MH, 1994a
Steenks MH, 1994b
Tasaki MM, 1993a
Tasaki MM, 1993b
Westesson P, 1987
Narrative reviews (09)
Benson BW, 1994
Berrett A, 1983
Heffez LB, 1993
Hayt MW, 2000
Popowich K, 2003
Vilanova JC, 2007
Vitale GJ, 1990
White SC, 2001
Winter AA, 2005
Studies that investigated
other TMJ disorders outside
the scope of the present
study or used a generic term
(i.e. intra articular disorders)
to classify the studied
sample (81)
Alexander SR, 1993
Ali IM, 2005
Arabshahi B, 2005
Arat ZM, 2001
Avrahami E, 1986
Baltali E, 2008;
Bell KA, 1993
Bell KA,1992
Bemporad JA, 1999
Bounds GA, 1987
Breul R, 1999
Breul R. 2007
Brooks SL, 1992
Cahill AM, 2007
Celiker R, 1995
Chintakanon K, 2000
Chirani RA, 2004
Christiansen EL, 1987
Church CA, 2003
Coutinho A, 2006
Conway WF, 1988
Conway WF, 1989
Curtin HD, 1983
de Almeida FR, 2002
Dolan EA, 1989
Eisenburger M,1999
Elias FM,2006
Epstein JB, 2002
Ercoli C, 1998
Estomaguio GA 2005
Gibbs SJ, 1998
Gidarakou IK, 2003
Hamada Y, 2001
Hamada Y, 2004
Hansson LG, 1996
Hardy CJ, 1988
Hendler N, 1996
Henry RG,2001
Hicks JL, 1993
Kalaykova S,2006
Kijima N, 2007
Kim KW, Han 2004
Kinzinger G, 2007
Kitai N, 2002
Larheim TA, 1992
Learreta JA. 1999
Learreta JA, 2005
Lieberman JM, 1996
Maeda M, 1992
Magnusson T, 2002
Manfredini D, 2003a
Manfredini D, 2003b
Mazza D, 2004
Miller VJ, 1997
Moystad A,2008
Orhan K, 2006
Pancherz H, 1999
Paulsen HU, 1995
Pereira LJ, 2004
Ramos-Remus C, 1997
Raustia AM, 1998
Sakabe R, 2006
Sartoris DJ, 1984
Schellhas KP, 1989
Schmelzeisen R, 2002
Schmitter M, 2005
Schmitter M, 2006
Seren E,1994
Silverstein R, 1994
Simon DC,1985
Spitzer WJ. 1990
Tognini F, 2003
Tsiklakis K, 2004
van der Kuijl B,
1990a
van der Kuijl B,
1990b
Vitral RW 2007
Wadhawan N, 2008
Westerman ST,
1991
Wilk RM, . 1988
Wong K 1999
Yeung RW, 2006
Studies that investigated
TMJD in relation to
systemic diseases (07)
Helenius LM, 2006
Küseler A, 1998
Küseler A, 2005
Major P, 1999
Melchiorre D, 2003
Smith HJ, 1992
Widmalm SE,
2006
Studies that did not use any
of the imaging methods
investigated in the study
(CT or MRI) (04)
Barrs DM, 1981
Drum R, 1987
White SC, 1995
Bertram S, 2001
Case reports (06)
Dorsay TA, 1995
Nakajima A 2005
Paz ME, 1988
Raustia AM, 1985
Roberts D, 1985
Tymofiyeva O,
2007
The main focus of the study
was not diagnosis (66)
Ahn SJ, 2007
Alexious K, 2009
Behnia H, 1997
Benbelaïd R, 2005
Benito C, 1998
Bernhardt O, 1999
Christiansen EL, 1987
Chu SA, 2001
Conway WF, 1991
Drace JE, 1990
El-Essawy, MT, 2008
Flores-Mir C, 2006
Flygare L, 1997
Fujimura K, 2004
Gaggl A, 1999
Gidarakou IK, 2003
Gökalp H, 2000
Gökalp H, 2005
Gökalp H. 2003
Gössi DB,2004
Helms CA, 1989
Hollender L, 1998
Imirzalioglu P, 2005
Kahn J, 1999
Kawakami M, 2006
Kinzinger G, 2006
Kitai N, 2004
Kulekcioglu S, 2003
Martinez Blanco M, 2004
Matsumura Y, 2004
McDevitt WE, 1995
McKenna SJ, 1996
Minakuchi H, 2004
Morinushi T, 1998
Moritz M, 1995
Murakami S, 1993
Nebbe B, 1997
Nishimura M, 2004
Ohta M, 2003
Pellizoni SE, 2006
Rao VM, 1993
Raustia AM, 1994
Raustia AM, 1995
Ruf S, 2002
Ruf S, 2000
Sano T, 2000
Schellhas KP, 1989
Schellhas KP, 1990
Schellhas KP, 1988
Schellhas KP, 1992a
Schellhas KP,1992b
Simmons HC 3rd, 2005
Suenaga S, 2001
Suenaga S, 1997
Sutton DI, 1992
Takahashi T, 1999
Tallents RH, 1996
Taşkaya-Yilmaz N,
2004
Tsuruta A 2004
Ueki K, 2005
Walter E, 1988
Watted N, 2001
Westesson PL,
1992
Wilkes CH. 1989
Yajima A, 2007
Yoshida H, 2000
62
Table 6
Criteria / Findings
The present study
Limchaichana
31
Aims
To evaluate the evidence for the diagnostic thinking and therapeutic efficacy of CT
and MRI in TMJD – disc displacement, inflammatory disorders (capsulitis,
synovitis), and osteoarthrosis
To evaluate the evidence for the efficacy of MRI in the diagnosis of disc
position and configuration, disc perforation, joint effusion, and osseous and
bone marrow changes in the temporomandibular joint.
TMJD
Disc displacement
Inflammatory disorders (capsulitis, synovitis)
Osteoarthrosis
Disc position and configuration
Disc perforation
Joint effusion
Osseous and bone marrow changes
Imaging methods
CT
MRI
MRI
Database names and date ranges searched were
documented
Yes
PubMed
Cochrane
January 1966 to July 2009
Yes
PubMed
January 1988 to June 2005
Electronic searches were performed in at least
two databases
Yes
No
Electronic searches were followed up with
secondary searches
Yes
Yes
All electronic search terms were presented in a
clear and reproducible manner
Yes
Yes
How the terms were combined was presented in
a clear and reproducible manner
Yes
Yes
A clear and reproducible inclusion/exclusion
criterion was provided
Yes
Yes
Included articles were selected by two or more
reviewers
Three reviewers
Two reviewers
All languages were included
Only English
Only English
Were used tools to assess the quality of primary
studies?
Yes
Quality, search method and article selection were evaluated using protocol
based on QUADAS
18
and criteria from publications that critically evaluate
systematic reviews.
130
Yes
Quality and internal validity were judged by a protocol based on
literature about critical appraisal of studies on diagnostic
methods.
10,28, 29, and Centre for Evidence-Based Medicine
(
www.cebm.net/worksheet_diagnosis.asp
)
Interpretation of the evidence from the literature
retrieved
One study was considered relevant in the evaluation of the thinking and therapeutic
efficacy. This study was a systematic review, shown in the next column of this table.
Key components of the quality assessment and a quality self-evaluation of this study
were reported.
No publication reported diagnostic thinking efficacy or therapeutic efficacy
Scores of level of diagnostic efficacy evidence were used (strong,
moderately strong, limited, or insufficient)
63
Appendix 1
First author: ...........................................................Article No. …..................................................................
Title: ………………………………………..................................................................................................
Journal: ……………………………….............................……….................................................................
Year: ……………….......... Volume: …….........… Pages: ………...............................................................
Examiner: .......................................................................................................................................................
• Was the aim of the study well defined?
Yes No
_____________________________________________________________________________________________
• Imaging methods used:
CT I Others________________________________________________________
• Diagnostic clinical criteria:
RDC /TMD Others_________________________________________________________
• TMJ disorders studied:
Disc displacement________________________________________________________________
______________________________________________________
______
• What was the efficacy level (Fryback and Thornbury) of this study?
Level 1 (Technical efficacy)
Resolution of line pairs
-scale range
uisition parameters
Level 2 (Diagnostic efficacy)
Observer performance expressed as overall agreement, kappa index, or correlation coefficients
iagnoses in case series)
clinical problem setting
Level 3 (Diagnostic thinking efficacy)
"helpful" in making the diagnosis
ilities between pre- and post-test information
-likelihood ratio for test positive and negative in a case series
Level 4 (Therapeutic efficacy)
Number or percentage of times image was judged helpful in planning management of the patient in a case
series
(retrospectively inferred from clinical records)
information
None
• Was diagnostic assessment the main focus of the study?
Yes No
If not, what was?
_____________________________________________________________________________________________
• Reviewer’s decision:
Study included
Comments: _______________________________________________________________________________
64
5. Conclusões / Considerações finais
Considerando o número reduzido de publicações que têm como foco a avaliação da
eficácia terapêutica da TC e RM nas desordens da articulação temporomandibular -
deslocamento de disco, osteoartrose e desordens inflamatórias sem envolvimento sistêmico
– conclui-se que há pouca evidência da contribuição da TC e RM para os pacientes com
essas desordens. Desta forma, a prescrição desses exames para estes pacientes deve ser
realizada de forma criteriosa e estudos devem ser realizados com o intuito de verificar a
evidência da eficácia terapêutica dos exames por imagem da articulação
temporomandibular.
A hipótese do trabalho foi comprovada em parte, pois, diante do número reduzido
de estudo que foi considerado relevante (apenas 1 publicação), não se pode chegar a uma
conclusão sobre a existência de eficácia terapêutica dos exames em estudo, na osteoartrose
e desordens inflamatórias aguda.
Novos caminhos…
Os resultados encontrados indicam a necessidade dos estudiosos serem mais
sistemáticos na realização de suas pesquisas. Somando-se a este fato as controvérsias no
diagnóstico e plano de tratamento das DATM, verifica-se que, para métodos de
diagnóstico possam efetivamente contribuir com o tratamento dos pacientes, a ponto de
gerar um impacto social, investimentos devem ser feitos em estudos de decisões clinicas.
Uma reorientação na avaliação do paciente baseada em critérios clínicos de diagnóstico e
de prescrição de exames por imagem, bem estabelecidas, permite estudos bem delineados e
uma avaliação eficaz dos métodos por imagem seccionais, TC e RM, nos cuidados com os
pacientes com DTM.
Esse trabalho trouxe um questionamento que inspira novas pesquisas:
Qual o impacto de se provar que um determinado método por imagem é
acurado se não se sabe qual o benefício deste resultado para o paciente?
65
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Apêndices
Apêndice 1 – Protocolo utilizado para leitura dos artigos na íntegra e seleção daqueles que preenchem os critérios de inclusão.
PROTOCOLO 1
Primeiro autor: .............................................................Artigo No. …..........................................................................................................................
Titulo: ………………………………………………..…...........….................................………………………………………………….………….
Revista: ……………………………………………………..........................……….................................................................................................…
Ano:………………..........…………..….Volume:……………......…Pags: ………...................................................................................................…
Examinador: ...............................................................................................................................................................................................................
1. O objetivo do estudo esta claramente determinado:
Sim
Não
________________________________________________________________________________________________________________
2. Qual o exame por imagem usado:
TC
RM
Outros______________________________________________________________________________________________________
3. Critérios clínicos de diagnóstico foram utilizados:
Sim
RDC /TMD
Outos______________________________________________________________________________________________________
Não
4. Qual a desordem da ATM em estudo:
Deslocamento do disco________________________________________________________________________________________
Desordens inflamatórias_______________________________________________________________________________________
Osteoartroses________________________________________________________________________________________________
Outros _____________________________________________________________________________________________________
Nenhum
5. Qual o nível de eficácia ( Fryback and Thornbury, 1991) deste estudo:
Nível 1 (Eficácia daTécnica)
Resolução de pares de linhas
Alterações na modulação de transferência de função
Variação da escala de cinzas
Matizes
Nitidez
Parâmetros de aquisição de imagem
Nível 2 (Acurácia-eficácia de Diagnóstico)
Concordância entre observadores expressa como concordância global, índice Kappa ou coeficiente de correlação.
Número de diagnóstico anormais e normais em uma série de casos
Acurácia de diagnóstico como porcentagem de diagnósticos corretos em uma série de casos
Sensibilidade, especificidade ou valores preditivos positivos/negativos em um conjunto de problemas clínicos definidos
Medidas de altura ou da área sob a curva ROC (Receiver Operating Characteristic Curve)
Nível 3 (Eficácia de diagnóstico clínico )
Número (porcentagem) de casos em uma série, nos quais imagens foram julgadas “úteis” para o diagnóstico
Mudança na distribuição das probabilidades de diagnóstico diferencial
Diferença na estimativa subjetiva das probabilidade de diagnóstico pelos profissionais antes e depois da informação fornecida pelo do
método em teste
Razão empírica subjetiva log-probabilidade para testes positivo e negativo em uma série de casos
Nível 4 (Eficácia terapêutica )
Número (porcentagem) de vezes que a imagem foi julgada útil no planejamento do tratamento do paciente em uma série de casos
Porcentagem de vezes que um procedimento médico foi evitado com base na informação da imagem.
Número ou porcentagem de vezes que a terapia pré-teste mudou depois que a informação de imagem foi obtida (inferido
retrospectivamente dos registros clínicos).
Número ou porcentagem de vezes que o profissional mudou sua escolha terapêutica depois da informação do exame
Nenhum
6. Avaliação de diagnóstico era o foco do estudo:
Sim
Não
Se não, qual era? __________________________________________________________________________________________________
7. Decisão do revisor:
Estudo incluido
Estudo não incluido
Incerto
Comentários: _________________________________________________________________________________________________________
82
Apêndice 2 – Protocolo para análise da qualidade das publicações baseado no QUADAS – Quality Assessment of Diagnostic
Accuracy Studies e publicações que avaliam criticamente as revisões sistemáticas. (WHITING et al 2003, WHITING et al 2005a,
WHITING et al 2005b, FLORES-MIR et al.,2006).
PROTOCOLO 2
Primeiro autor...........................................................................................................Artigo no………………........….……..
Examinador:............................................................................................................................................................................
Item
Sim
Não
1. Os objetivos do estudo foram claramente descritos?
2. Os critérios de inclusão/exclusão foram claramente descritos e reprodutíveis?
3. Todas as línguas foram incluídas?
4. Os artigos incluídos foram selecionados por dois ou mais revisores?
5. Os termos de busca eletrônica foram apresentados de uma forma clara e reprodutível?
6. A maneira como os termos foram combinados foram apresentados de uma forma clara e
reprodutível?
7. Uma apropriada estratégia de busca foi realizada ?
8. A estratégia de busca foi realizada em pelo menos duas bases de dados?
9. O nome das bases de dados e o intervalo de datas que restringiriam o ano das publicações
incluídas foram descritos?
10. Após a busca eletrônica, estratégias de busca adicionais foram realizadas?
11. O cenário atual do objetivo do estudo justifica sua realização?
12. As razões para exclusões das publicações foram descritas?
13. Foi usado instrumento para avaliação da qualidade dos estudos primários?
14. O instrumento usado para avaliação dos estudos primários foi sistematicamente
desenvolvido e direcionado para revisões sistemáticas sobre acurácia de diagnóstico?
15. Os achados e conclusões respondem a questão original do estudo?
83
Apêndice 3 - Publicações que foram selecionadas para leitura na íntegra e excluídas por não apresentarem critérios de inclusão na
amostra.
Estudos de
Espécimes de
cadáver (11)
Revisões
da literatura
(9)
Publicações
sobre outras
desordens não
consideradas
nos critéios de
inclusão da
amostra (79)
Publicaçõe
s sobre
DATM
associados
a doenças
sistêmicas
(7)
Publicações
sobre
DATM com
ténicas por
imagem não
inseridas
nos critérios
de inclusão
da amostra
(4)
Relatos
de caso (6)
Publicações
em que
nenhum
nível de
eficácia foi
investigado
(65)
Burnett KR,
1987
Cavalcanti
MG, 1999
Christiansen
EL. 1986
Drace JE, 1990
Hansson LG,
1989
Quemar JC,
1989
Steenks MH,
1994a
Steenks MH,
1994b
Tasaki MM,
1993a
Tasaki MM,
1993b
Westesson P,
1987
Benson BW,
1994
Berrett A, 1983
Hayt MW,
2000
Heffez LB,
1993
Popowich K,
2003
Vilanova JC,
2007
Vitale GJ,
1990
White SC,
2001
Winter AA,
2005
Alexander SR,
1993
Ali IM, 2005
Arabshahi B,
2005
Arat ZM, 2001
Avrahami E,
1986
Baltali E,
2008;
Bell KA, 1993
Bell KA,1992
Bemporad JA,
1999
Bounds GA,
1987
Breul R, 1999
Breul R. 2007
Brooks SL,
1992
Cahill AM,
2007
Celiker R,
1995
Chintakanon
K, 2000
Chirani RA,
2004
Christiansen
EL, 1987
Church CA,
2003
Coutinho A,
2006
Curtin HD,
1983
de Almeida
FR, 2002
Dolan EA,
1989
Eisenburger
M,1999
Elias FM,2006
Epstein JB,
2002
Ercoli C, 1998
Estomaguio
Helenius
LM, 2006
Küseler A,
1998
Küseler A,
2005
Major P,
1999
Melchiorre
D, 2003
Smith HJ,
1992
Widmalm
SE, 2006
Barrs DM,
1981
Bertram S,
2001
Drum R,
1987
White SC,
1995
Dorsay TA,
1995
Nakajima A
2005
Paz ME,
1988
Raustia AM,
1985
Roberts D,
1985
Tymofiyeva
O, 2007
Ahn SJ,
2007
Behnia H,
1997
Benbelaïd R,
2005
Benito C,
1998
Bernhardt O,
1999
Christiansen
EL, 1987
Chu SA,
2001
Conway WF,
1991
Drace JE,
1990
El-Essawy,
MT, 2008
Flores-Mir
C, 2006
Flygare L,
1997
Fujimura K,
2004
Gaggl A,
1999
Gidarakou
IK, 2003
Gökalp H,
2000
Gökalp H,
2005
Gökalp H.
2003
Gössi
DB,2004
Helms CA,
1989
Hollender L,
1998
Imirzalioglu
P, 2005
Kahn J,
1999
Kawakami
M, 2006
Kinzinger G,
2006
Kitai N,
2004
Kulekcioglu
S, 2003
Martinez
84
GA 2005
Gibbs SJ,
1998
Gidarakou IK,
2003
Hamada Y,
2001
Hamada Y,
2004
Hansson LG,
1996
Hardy CJ,
1988
Hendler N,
1996
Henry
RG,2001
Hicks JL, 1993
Kalaykova
S,2006
Kijima N, 2007
Kim KW, Han
2004
Kinzinger G,
2007
Kitai N, 2002
Larheim TA,
1992
Learreta JA.
1999
Learreta JA,
2005
Lieberman JM,
1996
Maeda M,
1992
Magnusson T,
2002
Manfredini D,
2003a
Manfredini D,
2003b
Mazza D,
2004
Miller VJ,
1997
Moystad
A,2008
Orhan K, 2006
Pancherz H,
1999
Paulsen HU,
1995
Pereira LJ,
2004
Ramos-Remus
C, 1997
Raustia AM,
1998
Sakabe R,
2006
Sartoris DJ,
1984
Schellhas KP,
Blanco M,
2004
Matsumura
Y, 2004
McDevitt
WE, 1995
McKenna SJ,
1996
Minakuchi
H, 2004
Morinushi T,
1998
Moritz M,
1995
Murakami S,
1993
Nebbe B,
1997
Nishimura
M, 2004
Ohta M,
2003
Pellizoni SE,
2006
Rao VM,
1993
Raustia AM,
1994
Raustia AM,
1995
Ruf S, 2002
Ruf S, 2000
Sano T, 2000
Schellhas
KP, 1989
Schellhas
KP, 1990
Schellhas
KP, 1988
Schellhas
KP, 1992a
Schellhas
KP,1992b
Simmons HC
3rd, 2005
Suenaga S,
2001
Suenaga S,
1997
Sutton DI,
1992
Takahashi T,
1999
Tallents RH,
1996
Taşkaya-
Yilmaz N,
2004
Tsuruta A
2004
Ueki K,
2005
Walter E,
1988
Watted N,
2001
Westesson
PL, 1992
85
1989
Schmelzeisen
R, 2002
Schmitter M,
2005
Schmitter M,
2006
Seren E,1994
Silverstein R,
1994
Simon
DC,1985
Spitzer WJ.
1990
Tognini F,
2003
Tsiklakis K,
2004
van der Kuijl
B, 1990a
van der Kuijl
B, 1990b
Vitral RW
2007
Wadhawan N,
2008
Westerman ST,
1991
Wilk RM, .
1988
Wong K 1999
Yeung RW,
2006
Wilkes CH.
1989
Yajima A,
2007
Yoshida H,
2000
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