Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for clinical and research applications: Recommendations of the international RDC/TMD consortium network and orofacial pain special interest group

Eric Schiffman, Richard Ohrbach, Edmond Truelove, John Look, Gary Anderson, Jean Paul Goulet, Thomas List, Peter Svensson, Yoly Gonzalez, Frank Lobbezoo, Ambra Michelotti, Sharon L. Brooks, Werner Ceusters, Mark Drangsholt, Dominik Ettlin, Charly Gaul, Louis J. Goldberg, Jennifer A. Haythornthwaite, Lars Hollender, Rigmor JensenMike T. John, Antoon De Laat, Reny de Leeuw, William Maixner, Marylee van der Meulen, Greg M. Murray, Donald R. Nixdorf, Sandro Palla, Arne Peterssonss, Paul Pionchon, Barry Smith, Corine M. Visscher, Joanna Zakrzewska, Samuel F. Dworkin

Research output: Contribution to journalArticlepeer-review

1179 Scopus citations

Abstract

Aims: The original Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms have been demonstrated to be reliable. However, the Validation Project determined that the RDC/TMD Axis I validity was below the target sensitivity of ≥ 0.70 and specificity of ≥ 0.95. Consequently, these empirical results supported the development of revised RDC/TMD Axis I diagnostic algorithms that were subsequently demonstrated to be valid for the most common pain-related TMD and for one temporomandibular joint (TMJ) intra-articular disorder. The original RDC/TMD Axis II instruments were shown to be both reliable and valid. Working from these findings and revisions, two international consensus workshops were convened, from which recommendations were obtained for the finalization of new Axis I diagnostic algorithms and new Axis II instruments. Methods: Through a series of workshops and symposia, a panel of clinical and basic science pain experts modified the revised RDC/TMD Axis I algorithms by using comprehensive searches of published TMD diagnostic literature followed by review and consensus via a formal structured process. The panel's recommendations for further revision of the Axis I diagnostic algorithms were assessed for validity by using the Validation Project's data set, and for reliability by using newly collected data from the ongoing TMJ Impact Project-the follow-up study to the Validation Project. New Axis II instruments were identified through a comprehensive search of the literature providing valid instruments that, relative to the RDC/TMD, are shorter in length, are available in the public domain, and currently are being used in medical settings. Results: The newly recommended Diagnostic Criteria for TMD (DC/TMD) Axis I protocol includes both a valid screener for detecting any pain-related TMD as well as valid diagnostic criteria for differentiating the most common pain-related TMD (sensitivity ≥ 0.86, specificity ≥ 0.98) and for one intra-articular disorder (sensitivity of 0.80 and specificity of 0.97). Diagnostic criteria for other common intra-articular disorders lack adequate validity for clinical diagnoses but can be used for screening purposes. Inter-examiner reliability for the clinical assessment associated with the validated DC/TMD criteria for pain-related TMD is excellent (kappa = 0.85). Finally, a comprehensive classification system that includes both the common and less common TMD is also presented. The Axis II protocol retains selected original RDC/TMD screening instruments augmented with new instruments to assess jaw function as well as behavioral and additional psychosocial factors. The Axis II protocol is divided into screening and comprehensive selfreport instrument sets. The screening instruments' 41 questions assess pain intensity, pain-related disability, psychological distress, jaw functional limitations, and parafunctional behaviors, and a pain drawing is used to assess locations of pain. The comprehensive instruments, composed of 81 questions, assess in further detail jaw functional limitations and psychological distress as well as additional constructs of anxiety and presence of comorbid pain conditions. Conclusion: The recommended evidence-based new DC/TMD protocol is appropriate for use in both clinical and research settings. More comprehensive instruments augment short and simple screening instruments for Axis I and Axis II. These validated instruments allow for identification of patients with a range of simple to complex TMD presentations.

Original languageEnglish (US)
Pages (from-to)6-27
Number of pages22
JournalJournal of Oral and Facial Pain and Headache
Volume28
Issue number1
DOIs
StatePublished - 2014

Bibliographical note

Funding Information:
Research performed by the Validation Project Research Group was supported by NIH/NIDCR U01-DE013331. The development of the examination specifications in support of the diagnostic criteria was also supported by NIH/NIDCR U01-DE017018 and U01-DE019784. Reliability assessment of Axis I diagnoses was supported by U01-DE019784. Workshop support was provided by the International Association for Dental Research, Canadian Institute for Health Research, International RDC/ TMD Consortium Network, Medotech, National Center for Biomedical Ontology, Orofacial Pain Special Interest Group of the International Association for the Study of Pain, and Journal of Oral Rehabilitation. The authors thank the American Academy of Orofacial Pain for their support; Terrie Cowley, president of the TMJ Association, for her participation in the Miami workshop; and Dr Vladimir Leon-Salazar for his assistance with finishing the manuscript. The Taxonomy Committee was composed of Jean-Paul Goulet, Thomas List, Richard Ohrbach (chair), and Peter Svensson. The authors report no conflicts of interest related to this study.

Funding Information:
Research performed by the Validation Project Research Group was supported by NIH/NIDCR U01-DE013331. The development of the examination specifications in support of the diagnostic criteria was also supported by NIH/NIDCR U01-DE017018 and U01-DE019784. Reliability assessment of Axis I diagnoses was supported by U01-DE019784. Workshop support was provided by the International Association for Dental Research, Canadian Institute for Health Research, International RDC/TMD Consortium Network, Medotech, National Center for Biomedical Ontology, Orofacial Pain Special Interest Group of the International Association for the Study of Pain, and Journal of Oral Rehabilitation. The authors thank the American Academy of Orofacial Pain for their support; Terrie Cowley, president of the TMJ Association, for her participation in the Miami workshop; and Dr Vladimir Leon-Salazar for his assistance with finishing the manuscript. The Taxonomy Committee was composed of Jean-Paul Goulet, Thomas List, Richard Ohrbach (chair), and Peter Svensson. The authors report no conflicts of interest related to this study.

Keywords

  • Diagnostic criteria
  • Diagnostic reliability
  • Diagnostic validity
  • Sensitivity
  • Specificity
  • Temporomandibular disorders

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