Network Symposium to be presented at IADR, Barcelona, Spain, July 2010

Session Title: Diagnostic Criteria for TMD (DC/TMD): A new version of the RDC/TMD
Group(s): International RDC/TMD Consortium Network/Neuroscience
Session Type: SymposiumGroup/Division Sponsored
Description: The RDC/TMD has been a successful approach for classifying the most
common types of TMD. The classification system was introduced in 1992; since then, it has
been translated into 20 languages and cited in an overwhelming number of publications.
Recently, the NIDCR funded a large, multi-site study to examine the reliability and validity of
the RDC/TMD and, as appropriate, to recommend revisions to that protocol. These revisions
were further developed into the Diagnostic Criteria for TMD (DC/TMD)a new version of
the RDC/TMDin an International Consensus Workshop at the 2009 IADR meeting. This
symposium should be accessible to experienced investigators, academic clinicians, and basic
scientists interested in opportunities for TMD research.
Program: The symposium will present comments and recommendations from the DC/TMD
workshop. All symposium speakers were involved in the development of these criteria.
Thomas List and Mark Drangsholt (moderators) will begin with a short introduction to the
new criteria and an orientation in its use in clinical praxis and in research settings. Three
topics will then be presented:

Diagnostic algorithms for myofascial pain and headache attributed to TMD. Jean-Paul
Goulet (University of Laval, Quebec City, Canada)experienced clinician with
research experience in diagnostic accuracy.

Diagnostic algorithms for TMJ disorders. Eric Schiffman (University of Minneapolis,

Minnesota, USprincipal investigator of the NIDCR/NIH-funded project Research
Diagnostic Criteria: Reliability and Validity.

Assessment of the behavioral domain in TMD. Richard Ohrbach (University at

Buffalo, US)psychologist, experienced clinician, and co-principal investigator of the
NIDCR-sponsored validation project.

Educational Objectives:
1. Present instruments for screening and examining TMD patients in clinical praxis and
research settings.
2. Discuss specifications for diagnosing muscle and TMJ disorders.
3. Present instruments for assessing the behavioral domain in pain.
Organizers and Moderators: Thomas List (Malm University, Sweden) and Mark Drangsholt
(University of Washington, Seattle, WA, US)

Diagnostic Criteria for

Temporomandibular Disorders (DC/TMD):
A new version of the Research
Diagnostic Criteria for TMD (RDC/TMD)

Thomas List, Malm University

Jean-Paul Goulet, Laval University
Eric Schiffman, University of Minnesota
Richard Ohrbach, University at Buffalo
Mark Drangsholt, University of Washington

A Symposium held at the IADR/Barcelona, July 2010

Program
From the RDC/TMD to the DC/TMD
Thomas List
Diagnostic algorithms for myofascial pain and headache
attributed to TMD.
Jean-Paul Goulet
Diagnostic algorithms for TMJ disorders.
Eric Schiffman
Assessment of the behavioral domain in TMD
Richard Ohrbach
Summary
Mark Drangsholt

From RDC/TMD to DC/TMD

Thomas List
1992

RDC/TMD published JOP.

2008, IADR Toronto

Validation Studies of the

RDC/TMD: Progress toward
Version 2.

2009, IADR Miami

International Consensus
Workshop:Convergence on an
Orofacial Pain Taxonomy.

2010/2011

DC/TMD submitt JADA.

RDC/TMD

Comprises:
A dual axis approach.
Clearly operationalized
data collection procedures.
Strict diagnostic criteria.

RDC/TMD
Has been used in a wide range of experimental, clinical,
and population-based studies among adults and
adolescents around the world.
Is translated into 20 languages.
Is one of the most commonly cited references in dental
literature. A search in Web of Science generated 918
citations.

Critical review of RDC/TMD

The diagnostic criteria for the physical
diagnosis need to be refined.
The range of disorders represented by the
RDC/TMD needs to be expanded.
The assessment domains comprising Axis
II need to be reviewed and potentially
updated.

The NIDCR sponsored project the

RDC/TMD Validation Project
2001-2006
The Research Diagnostic Criteria for TMD
I: overview and methodology for assessment of
validity.
II: reliability of Axis I diagnoses and selected clinical
measures.
III: validity of Axis I diagnoses.
IV: evaluation of psychometric properties of the Axis
II measures.
V: methods used to establish and validate revised
Axis I diagnostic algorithms.
VI: future directions.
Research diagnostic criteria for temporomandibular
disorders (RDC/TMD): development of image
analysis criteria and examiner reliability for image
analysis.

IADR Toronto 2008

Validation Studies of the RDC/TMD: Progress towards
Version 2
Jean-Paul Goulet
John Look, Eric Schiffman,
Edmond Truelove, Mansur
Ahmad, Richard Ohrbach.
Frank Lobbezoo, Sandro
Palla. Bouwijn Stegenga,
Mike John, Rigmor Jensen,
Arne Petersson, Jennifer
Haythornthwaite, Samuel
Dworkin.
Peter Svensson, Chuck
Green

IADR Miami 2009

International Consensus Workshop:
Convergence on an Orofacial Pain Taxonomy
Workshop goals
Finalize the revision of the RDC/TMD into a Diagnostic
Criteria for Temporomandibular Disorders (DC/TMD),
which would be more appropriate for routine clinical
implementation
Provide a broad foundation for the further development
of suitable diagnostic systems for not only TMD but also
orofacial pain.
Provide research recommendations to improve our
understanding of TMD and orofacial pain

IADR Miami
International Consensus Workshop:
Convergence on an Orofacial Pain Taxonomy

Workshop participation:

International RDC/TMD Consortium Network

SIG Orofacial Pain
NIDCR
American Academy of Orofacial Pain
European Academy of Craniomandibular Disorders
International Headache Society
Other disciplines included: radiology, psychology,
ontology, neurology and patient advocacy.

Description of the Workshop

Presentations: Systematic review
guidelines, biomedical ontology
and patient advocacy.
Workgroup made revisions of
respective parts of the RDC/TMD
Each workgroup presented the
recommendations for critique by
the others.
Delphi-like voting for determing
whether sufficient concensus had
been achieved.

IADRSymposium,Barcelona,2010

Outline
1. RDC/TMD(1992)requirements forthediagnosis
of GroupI Musclesdisorders
2. DC/TMDfor GroupI Musclesdisorders
3. Specifications forclinical assessment:
RDC/TMDvsDC/TMD

4. Headache attributed toTMD

5. Futureaspects

JPG/FMD
JPG/FMDUL

JPG/FMD
JPG/FMDUL

RDC/TMD(1992)ALGORITHM
Ongoing painintheface,jaw,temple,inthepast month?

NO

YES

Totalnumber oftendermusclesitesoutof20

<3

3 or >

Ongoing painonsame side aspalpationpain

NO

YES

Painfreeopening
(with verticalincisaloverlap)
< 5 mm
40 mm or >

< 40 mm

Passivestretch(MAO UOWoP)
5 mm or >

MYOFASCIALPAIN

MYOFASCIALPAIN
WITH
LIMITEDOPENING

NOGROUPI
DIAGNOSIS
JPG/FMD
JPG/FMDUL

GROUPI:MUSCLEDISORDERS
RDC/TMD
(1992)

RDC/TMD
Revised *

DC/TMD**

Ia:Myofascialpainwith Ia:Myofascialpainwith
nolimited opening
nolimited opening

Ia:Myofascialpain

Ib:Myofascialpainwith Ib:Myofascialpain
limited opening
with limited opening

Ib:Myofascialpain
with referral

* Schiffman et al. J Orofacial Pain, 2010

** Miami Consensus Workshop, 2009
JPG/FMD
JPG/FMDUL

DC/TMDALGORITHMFORMYOFASCIALPAIN
Ongoing painintheface,jaw,temple,inthepast month AND pain
modificationwith movement,function andparafunction
PLUS
Examinerconfirmationofpainlocationinamasticatorystructure
PLUS
Atleast 1 masseter ortemporalis musclesitepainful topalpation
OR
Paininmasseter ortemporalis with maximumunassisted orassisted opening
PLUS
FAMILIARPAIN
YES

NO

REFERREDPAIN
onpalpationofthemasseter ortemporalis
NO

MYOFASCIAL
PAIN

YES

MYOFASCIAL
PAINWITH
REFERRAL

NOMYOFASCIAL
PAINDIAGNOSIS
JPG/FMD
JPG/FMDUL

MYOFASCIALPAINASSESSMENT
CLINICALHISTORY
Ongoing painintheface,jaw,
templeinthepast month?
Examinerconfirmationofpain
location
Painmodificationwith movement,
function andparafunction

RDC
1992

RDC
Revised

DC

JPG/FMD
JPG/FMDUL

MYOFASCIALPAINASSESSMENT
PHYSICALEXAMINATION

RDC
1992

RDC
Revised

DC

Patients reportofpainlocation

Musclepainupon palpation

Patients reportofmasseter or
temporalis painwith mandibular
opening

Patients reportof familiar pain

Patients reportof referred pain

Measurement oftheverticalrange
ofmotionofthemandible

JPG/FMD
JPG/FMDUL

MYOFASCIALPAINALGORITHMS
SENSITIVITY/SPECIFICITY
RDC/TMD
1992

RDC/TMD
Revised *

DC/TMD

Myofascialpainwith
nolimitation

0,75/0,97

0,82/0,99

n/a

Myofascialpain
with limitation

0,83/0,99

0,93/0,97

n/a

Myofascialpain

n/a

n/a

0,84/0,95

Myofascialpainwith
referral

n/a

n/a

0,85/0,98

Any myofascialpain

0,82/0,98

0,91/1,00

0,90/1,00

* Schiffman et al. J Orofacial Pain, 2010

JPG/FMD
JPG/FMDUL

MUSCLEPALPATIONSITES
RDC/TMD(1992)

DC/TMD

Extraoral musclesites(16)

Extraoral musclesites (12)

Temporalis anterior
Temporalis middle
Temporalis posterior
Masseter origin
Masseter body
Masseter insertion
Posterior mandibularregion
Submandibular region

Intraoral musclesites (4)

Temporalis anterior
Temporalis middle
Temporalis posterior
Masseter origin
Masseter body
Masseter insertion

Intraoral musclesites (0)

Lateral pterygoid area

Tendonoftemporalis
JPG/FMD
JPG/FMDUL

SPECIFICATIONSFORMUSCLE
PALPATION
RDC/TMD(1992)
2lbs ofpressurefor
temporalis andmasseter
musclesites
1lbofpressureforposterior
mandibularand
submandibular regions
1lbofpressureforintraoral
musclesites
n/a

DC/TMD
Minimumof2lbs ofpressure
(range23lbs)fortemporalis
andmasseter musclesites
n/a

n/a
Presence ofreferred pain
JPG/FMD
JPG/FMDUL

HEADACHE,TMD,OROFACIALPAIN

Gonalvez etal.2010

StormandWnman 2006

StudginskiBarbosa etal.
2010

Mitrirattanakul andMerril
2006

Bevilaqua Grossietal.2009
Ballegaard etal.2008

Ciancaglini andRadaelli
2001

Glaros etal.2007

Wattsetal.1986

Mongini 2007

JPG/FMD
JPG/FMDUL

SECONDARYHEADACHES
(ICHDII2004)
11.1
11.2
11.3
11.4
11.5
11.6

Headache attributed todisorder ofcranial bone

Headache attributed todisorder ofneck
Headache attributed todisorder ofeyes
Headache attributed todisorder ofears
Headache attributed torhinosinusitis
Headache attributed todisorder ofteeth,
jaws orrelated structures
11.7 Headache attributed toTMJdisorder
11.8 Headache attributed toother disorder of
cranium,neck,eyes,nose,sinuses,teeth,
mouth orother facialorcervicalstructuresJPG/FMD
JPG/FMDUL

11.7 HEADACHEORFACIALPAIN
ATTRIBUTEDTOTMJDISORDER(ICHDII2004)
A. Recurrent paininoneormoreregions ofthehead
and/orfacefulfilling criteria CandD
B. Xray,MRIand/orbone scintigraphy demonstrate TMJ
disorder
C. Evidencethat paincan be attributed totheTMJ
disorder based onatleastoneofthefollowing:
1. painis precipitated byjaw movements and/or
chewing ofhardortough food
2. reduced rangeoforirregular jaw opening
3. noisefrom oneorboth TMJs during jaw movements
4. tenderness ofthejoin capsule(s)ofoneorboth TMJs

D. Headache resolves within 3months,anddoes notrecur,

after successful tratment oftheTMJdisorder
JPG/FMD
JPG/FMDUL

SECONDARYHEADACHES
(REVISEDICHDII2009)
A. Headache ofany typefulfilling criteria CandD
B. Another disorder scientifically documented tobe ableto
causeheadache hasbeendiagnosed
C. Evidenceofcausationshown byatleast2ofthefollowing:
1.Headache hasoccurred intemporalrelationtotheonset ofthe
presumed causativedisorder
2.Headache hasoccurred orhassignificantly worsened intemporal
relationtotheworsening ofthethe presumed causativedisorder
3.Headache hasimproved intemporalrelationwith theimprovement
ofthethe presumed causativedisorder
4.Headachehascharacteristics typical ofthecausativedisorder
5.Otherevidenceexistsofcausation

D.

Theheadache is notbetter accounted forbyanother

headache diagnosis
JPG/FMD
JPG/FMDUL

HEADACHEATTRIBUTEDTOTMD
[SENSITIVITY0,83;SPECIFICITY0,86]*
A.

Mildtomoderateheadacheofanytype,fulfillingcriteriaCandD

B.

PainrelatedTMDdemonstratedbyclinicallybaseddiagnosticcriteria

C.

Evidenceofcausationshownbyatleast2ofthefollowing:
1. HeadachehasoccurredintemporalrelationtotheonsetofthepainrelatedTMD
2. Headachehasoccurredorhassignificantlyworsenedintemporalrelationto
worseningofthepainrelatedTMD
3. Headachehasimprovedintemporalrelationtoimprovementofthe painrelatedTMD
4. HeadachecanbeattributedtopainrelatedTMDbasedonthefollowing:
a.History:Selfreportedheadacheinthetemple(s)thatischangedwithjaw
movement,function,oralhabits,orrest
b.Examination:Reportoffamiliarheadacheinthetemplewithpalpationofthe
temporalis muscle(s)
5. Headacheislocated,atlastinpart,inthetempleregionoftheheadcorresponding
tothesiteofthetemporalis muscle(s)

D.

Theheadacheisnotbetteraccountedforbyanotherheadache
diagnosis
* Based on criteria A, C4, C5, D

JPG/FMD
JPG/FMDUL

OROFACIALPAIN

JPG/FMD
JPG/FMDUL

FUTUREASPECTS
Taxonomy that includes less common muscledisorders
Screeninginstrumentsformuscledisorders
Alternativemethods forgathering datarelevantto
muscledisorders
Comprehensive clinical phenotype ofmuscledisorders
Differential subtype utilityofmuscledisorders in
treatment decision making
Criteria forheadache attributed toAxisImuscle
disorders
DC/TMDandgeneral practitioners
JPG/FMD
JPG/FMDUL

ACKNOWLEDGMENTS
Sponsors and funding agencies
International RDC/TMD Consortium
Network
Orofacial Pain Special Interest Group
of the IASP
Canadian Institute for Health Research
International Association for Dental
research
National Center for Biomedical
Ontology
Medotech

Miami Consensus Workshop Participants

Muscle Disorders and Headache: Gary
Anderson, Yoly Gonzalez, Jean-Paul
Goulet, Rigmor Jensen, Bill Maixner,
Ambra Michelotti, Greg Murray, Corine
Visscher.

General members: Sharon Brooks, Werner

Ceusters, Terri Cowley, Don Denucci,
Mark Drangsholt, Sam Dworkin, Dominic
Ettlin, Charly Gaul, Lou Goldberg,
Jennifer Haythornthwaite, Lars Hollender,
Mike John, John Kusiak, Antoon deLaat,
Reny deLeeuw, Thomas List, Frank
Lobbezoo, John Look, Marylee van der
Meulen, Don Nixdorf, Richard Ohrbach,
Sandro Palla, Arne Petersson, Paul
Pionchon, Eric Schiffman, Barry Smith,
Peter Svensson, Joanna Zakrzewska.
JPG/FMD
JPG/FMDUL

JPG/FMD
JPG/FMDUL

IADR Symposium, Barcelona, 2010

Overview
1. TMD diagnostic algorithms:
Arthralgia, Disc Displacements
and Degenerative Joint Disease
* RDC/TMD (1992)
* Revised RDC/TMD (2010)
* New DC/TMD
2. Changes from RDC/TMD to
DC/TMD
3. Future direction

Arthralgia, Arthritis, & Arthrosis

RDC/TMD
(1992)

Revised
RDC/TMD
(2010)

DC/TMD

In last month, ongoing pain in the

face, jaw, temple, in front of the
ear or in the ear

--

Pain modification with movement,

function and parafunction

--

--

--

--

CLINICAL HISTORY
ARTHRALGIA

ARTHRITIS & ARTHROSIS

In last month, any noise present

Arthralgia, Arthritis, & Arthrosis

RDC/TMD
(1992)

Revised
RDC/TMD
(2010)

DC/TMD

Patient report of pain location

--

--

Pain with joint palpation

Lateral pole
Posterior
Around lateral pole

--

Pain with ROM

including protrusive

--

--

Familiar pain with palpation and ROM

--

Fine crepitus with palpation

Coarse crepitus with palpaton
Coarse crepitus is audible

-
--

--

Crepitus detected by subject with ROM

--

PHYSICAL EXAM
ARTHRALGIA

ARTHRITIS and ARTHROSIS

Sensitivity and Specificity for Arthralgia, and

Degenerative Joint Disease
Sensitivity

Specificity

RDC/
TMD

Revised

DC/
TMD

RDC/
TMD

Revised

DC/
TMD

1. Arthralgia

0.38

N/A

N/A

0.90

N/A

N/A

2. Osteoarthritis

0.13

N/A

N/A

1.00

N/A

3. Osteoarthrosis

0.12

N/A

N/A

0.99

N/A

N/A
N/A

4. Joint Pain
(1+2)

0.42 0.92 0.91 0.99

0.96 0.96

5. Degenerative
Joint Disease
(2+3)

0.14 0.52 0.40 0.99

0.86 0.91

DC/TMD ARTHRALGIA
I. History is positive for both of the following:
Ia. In last month, ongoing pain in the face, jaw, temple,
in front of the ear or in the ear
AND
Ib. Pain modification with movement, function and parafunction
AND
II. Examination of the joint produces report of familiar pain by at
least 1 of the following provocation tests:
IIa. Palpation of the lateral pole or around the lateral pole
OR
IIb. Range of motion: Maximum unassisted or assisted
opening, right or left lateral movements, or protrusive
movement
Sensitivity 0.91 / Specificity 0.96

DC/TMD
Degenerative Joint Disease
History is positive for the following:
I. In last month, any noise present
AND
Examination is positive for at least one of the following:
IIa. Crepitus* detected with palpation during maximum
unassisted opening, maximum assisted opening,
lateral movements, or protrusive movements,
OR
IIb. Report of crunching, grinding or grating noises
* Fine or coarse crepitus
Sensitivity 0.40/ Specificity 0.91

Disc Displacements
RDC/TMD
(1992)

Revised
RDC/TMD
(2010)

DC/TMD

In last month, noise present

--

Hx of significant limitation

2 of 3

1 of 3

1 of 3

5 mm between reciprocal clicks

--

--

Elimination of click

--

--

Unassisted: > 35 mm
Stretch: 5 mm

Stretch:
40 mm

Stretch:
40 mm

Lateral & protrusive movement

7 mm

--

--

Uncorrected opening deviation

--

--

CLINICAL HISTORY

PHYSICAL EXAM

Click detection

Vertical opening (corrected)

Sensitivity and Specificity for

Disc Displacements
Sensitivity

Specificity

RDC/TMD

Revised

DC/TMD

RDC/TMD

Revised

DC/TMD

Disc Displacement
with Reduction

0.42

0.46

0.33

0.92

0.90

0.94

Disc Displacement
with Reduction
with Intermittent
Locking

N/A

N/A

0.46

N/A

N/A

0.97

Disc Displacement
without Reduction
with Limited

0.26

Disc Displacement
without Reduction
without Limited

0.05

0.53

0.54

0.99

0.80

0.79

Any Disc
Displacement

0.35

0.71

0.67

0.96

0.67

0.69

0.80 0.80

1.00

0.97 0.97

Disc Displacement with Reduction

History is positive to the following:
I.
In the last month, any noise present

AND
Examination:
IIa. Opening and closing click during at least 1 of 3 repetitions of jaw
opening and closing,

OR
IIb. Either an opening or closing click during at least 1 of 3
repetitions of opening and closing,
and
A click during at least 1 of 3 repetitions of each of the
excursive movements (left lateral, right lateral, or protrusion)
Sensitivity 0.33 / Specificity 0.94

DC/TMD Disc Displacement with

Reduction with Intermittent Locking
History is positive to both of the following:
Ia. In the last month, any noise present
AND
Ib. In last month, report of intermittent locking
with limited opening
AND
Examination:
IIa. Same as disc displacement with reduction
Sensitivity 0.46 / Specificity 0.97

DC/TMD Disc Displacement without

Reduction with Limited Opening
History is positive for both of the following:
Ia. Jaw lock or catch so that it would not open all the way
AND
Ib. Limitation in jaw opening severe enough to interfere
with ability to eat.
AND
Examination is positive for the following:
II. Maximum assisted opening (passive stretch)
< 40mm including vertical incisal overlap
Sensitivity 0. 80 / Specificity 0.97

DC/TMD Disc Displacement without

Reduction without Limited Opening
History is positive for both of the following:
I. Same as disc displacement without reduction with
limited opening
AND
Examination is positive for the following:
II. Maximum assisted opening (passive stretch)
> 40mm including vertical incisal overlap
Sensitivity 0.54 / Specificity 0.79

SUMMARY: DC/TMD
1.

Valid diagnostic criteria for TMD muscle and joint

pain for use in the clinical and research settings.

2.

TMD pain is is the most common reason patients

seek care.

3.

Diagnosis of TMJ intra-articular disorders

a. DD without reduction with limited opening
is reliable and valid.
b. MRI is needed to definitively diagnosis ALL
other types of disc displacements
c. CT is needed for DJD

Future Direction
1. Determine the clinical utility of subdividing arthralgia
consistent with ICHD:
Infrequent episodic/ frequent episodic/ chronic arthralgia.

2.

3.
4.
5.

Determine the clinical significance of disc displacements and

degenerative joint disease to patient-reported outcomes of
pain, functional limitations and disability since imaging is
needed to definitively diagnosis of these disorders.
Expand the taxonomic system to include less common joint
disorders using the AAOP DC* for these disorders
DC/TMD for phenotyping individuals for research and for
clinical use.
Develop RDC/TMDv2 for advancing our knowledge base to
better diagnose TMD.

* Best current source of expert-based DC

Miami Consensus Workshop Participants

Planning Committee:
Jean-Paul Goulet, Thomas List, Richard Ohrbach and Peter Svensson.
General members:
Gary Anderson, Sharon Brooks, Werner Ceusters, Terri Cowley, Don
Denucci, Mark Drangsholt, Sam Dworkin, Dominic Ettlin, Charly Gaul, Lou
Goldberg, Yoly Gonzalez, Jennifer Haythornthwaite, Lars Hollender, Rigmor
Jensen, Mike John, John Kusiak, Antoon deLaat, Reny deLeeuw,, Frank
Lobbezoo, John Look, Bill Maixner, Marylee van der Meulen, Ambra
Michelotti, Greg Murray, Don Nixdorf, Sandro Palla, Arne Petersson, Paul
Pincion, Eric Schiffman, Barry Smith, Corine Visscher and Joanna
Zakrzewska.
Sponsors and funding agencies
International RDC/TMD Consortium Network
Orofacial Pain Special Interest Group of the IASP
Canadian Institute for Health Research
International Association for Dental research
National Center for Biomedical Ontology
Medotech

IADR Symposium, Barcelona 2010

Diagnostic Criteria for TMD (DC/TMD): A new version of the RDC/TMD

AssessmentofthebehavioraldomaininTMD
EvolutionofAxisII:RDC/TMD(1992)totheDC/TMD

RichardOhrbach,DDSPhD
UniversityatBuffalo
SchoolofDentalMedicine
DepartmentofOralDiagnosticSciences

WhyAxisII?
Biobehavioral axis:assess,asascreener,
characteristicsofthepersonthatdescribethe
impactofpain,affectpainperception,and
contributetoprognosis
PresentationOverview
RDC/TMDAxisII
ValidationProject
ConsensusWorkshopRecommendations
ProblemswithRDC/TMDAxisII
IntegratedAssessmentModel
TailoredAssessment
Summary

RDC/TMDAxisII:Constructs
Assesscoresymptomsaffecting
painmodulationandcoping,and
indicativeofmorbidity
Nonspecificphysicalsymptoms Assessphysicalsymptoms
[associatedwithfunctional
(SCL90)
somaticsyndromes]
GradedChronicPain
Hierarchicaldisabilityclassification
oflifeinterferenceduetopain
(GradedChronicPainScale)
Representativeindexofpain
Characteristicpainintensity
severitythatintegratestimeand
(GradedChronicPainScale)
fluctuations
Assesswiderangeofpotential
JawDisabilityChecklist
functionsaffectedbyjaw
(adhoc)
problems
Depression
(adaptedfromSCL90)

Axis II Psychometric Properties - 1

InternalConsistencyandTemporalStabilityofAxisIIMeasures
Cronbachs
LinsCCC
Measure
Alpha
orKappa
Depression
0.91
0.78
NonspecificPhysicalSymptoms

0.84

0.72

CharacteristicPainIntensity
PainInterference
ChronicPainGrade

0.84
0.95
N/A

0.91
0.89
0.87

Internal consistency is sufficient for all measures to be used for

screening.
Temporal stability ranges from 0.72 0.91, reflecting the
dynamic character of the measured constructs.
Ohrbach et al, Journal of Orofacial Pain, 2010

Axis II Psychometric Properties - 2

ConvergentandDiscriminantValidity
AxisIIMeasure
Depression

Nonspecific
Physical
Symptoms

GCPPain
Intensity

GCP
Inter
ference

Chronic
Pain
Grade

CESD

0.85

0.57

0.20

0.30

0.21

GHQ28SomaticSxs

0.38

0.46

0.23

0.29

0.19

MPI:AffectDistress

0.59

0.42

0.13

0.20

0.15

MPI:PainSeverity

0.29

0.46

0.65

0.47

0.37

MPI:GenActivity

0.17

0.13

0.02

0.09

0.07

MPI:Interference

0.32

0.41

0.42

0.52

0.44

MPI:Dysfunctional

0.58

0.54

0.44

0.51

0.35

SF12v2:PCS

0.03

0.28

0.22

0.33

0.26

SF12v2:MCS

0.70

0.42

0.08

0.20

0.12

ValidityMeasure

Ohrbach et al, Journal of Orofacial Pain, 2010

Axis II Psychometric Properties - 3

CriterionValidity(%)of
DepressionandNonspecificPhysicalSymptoms
CriterionPsychDx: AnyPsychiatricDx:
CurrentYear
Lifetime
AxisIIMeasuresand
Sens
Spec
Sens
Spec
cutpoints
Depression(SCL90)
Normalvs modsevere

87

53

68

60

Normalmodvs severe

56

91

34

98

NonspecificPhysicalSymptoms(SCL90)
Normalvs modsevere

86

31

74

36

Normalmodvs severe

68

68

45

82

Ohrbach et al, Journal of Orofacial Pain, 2010

0.75

1.00

ROC Curve: Axis II Depression Measure

vs DSM Depression Diagnosis

Sensitivity
0.50

1 Moderate cutpoint

0.25

2 Severe cutpoint

0.00

3 Optimal visual cutoff for

moderate cutoff
0.00

0.25

Area under ROC curve = 0.8123

0.50
1 - Specificity

0.75

1.00

Improving and Expanding Axis II - 1

#
items

Adj*
StdOR

SCL90R

20

3.9

CenterEpidemiologicStudies

20

4.5

GenHealthQuestionnaire28

2.9

SCL90R

12

3.2

GenHealthQuestionnaire28

1.6

SCL90R

10

5.7

StateTraitAnxietyInventory

20

2.9

GenHealthQuestionnaire28

2.3

Criterion
fromDSM
Depressive
disorders
Somatic
Symptoms
Index
Anxiety
disorders

Measure

* Covariates include: gender, age, study site, pain intensity, interference, Axis I dx

Improving and Expanding Axis II - 2

Correlation anxiety with depression: 0.8

Outcome
DSM depression
disorders
DSM anxiety
disorders

Base model
Augmented model
Predictor adj* OR Predictor adj* OR
anxiety

5.3

anxiety
depression

1.8
5.5

depression

6.9

depression
anxiety

1.1
10.7

* Covariates include: gender, age, study site, pain intensity, interference, Axis I dx

Improving and Expanding Axis II - 3

Dependent variable: pain-related interference (MPI)
Predictor
SCLdepression

Add
adj *
depression:
OR
adj*OR
8.4

SCLnonspecificphysicalsymptoms

3.0

SCLanxiety

7.1

SCLobsessive

3.2

1.1

SCLinterpersonalsensitivity

4.8

1.5

SCLhostility

7.7

2.0

SCLparanoia

3.9

1.2

* Covariates include: gender, age, study site, pain intensity, interference, Axis I dx

Core Axis II for DC/TMD

Construct
Pain

Rating

Recommended Measure

#
items

Graded Chronic Pain Scale

Jaw behavior

Jaw Functional Limitations Scale

20

Parafunctional

Oral Behaviors Checklist

21

General

Graded Chronic Pain Scale

Co-morbid physical
symptoms

SCL-somatization

12

Co-morbid
syndromes

Self-reported syndrome checklist

(e.g., other pain conditions)

Depressive sxs

SCL-depression

20

Anxiety symptoms

SCL-anxiety

10

Function

TBD

Emotional Function

Total Number of Items

90+
Ohrbach et al, www.rdc-tmdinternational.org, 2010

ProblemswithRDC/TMDAxisII
Difficultyinusingthescreenersingeneral
treatmentsetting
toolong(depression)
hardtointerpret(nonspecificphysicalsymptoms)
toospecific(GradedChronicPainScale)

ClinicalapplicationoffindingsfromAxisII
IntegrationofAxisIIwithAxisI

IntegratedAssessmentModel
General dental treatment setting
Red & yellow flags (from interview)
Distress screener
Social disability screener
Research setting
[Core Axis II measures]
Supplemental Axis II
[Developmental Axis II]
Referral clinical setting
Core Axis II measures, OR
Comprehensive pain screener

Pain psychology setting

Core Axis II measures
Supplemental Axis II

TailoredAssessment
Initial or returning complainant patient

Distress and social disability screeners

Chronicity
Functional limitation
Discrepancy in findings
Medication overuse

Red flags?
Investigate
or refer

Clinical evaluation
History for yellow flags
Review screener responses

Inappropriate
behavior
expectations

Significant yellow flags?

yes

Investigate
or refer

treatment response
Psychosocial red flags

Treatment cycle and

scheduled review
JOR-CORE (Siena), 2009; Cairns et al (2010), J Oral Rehabil

Distressscreener:PHQ9
ItemContent
Lossofinterestorpleasure
Lowmoodorhopeless
Poorsleep
Lowenergy
Problemswithappetite
Poorselfesteem
Poorconcentration
Agitationorretardation
Suicidalideation
ForanyPOSITIVEresponses:
impactonyourselforothers?

RatingScale
Last2weeks
Notatall
Severaldays
Morethanhalfthedays
Nearlyeveryday

RatingScale
Notdifficultatall
Somewhatdifficult
Verydifficult
Extremelydifficult

Distressscreener:PHQ9
PsychometricProperties
Sample:6000primarycarepatients
Referencestandard:structuredinterviews
Domain
Parameter
Internalconsistency(Cronbachalpha)
Reliability
Temporalstability@48hrs(Pearsoncorr)

Validity

Utility

Statistic
0.89
0.84

Sensitivityrange
95 68%
Specificityrange
84 95%
Sens,spec(cutoff> 10)
88%,88%
Strongassocs:dis days,sx disability,physicianvisits
Sensitivitytochange(effectsizerange)*
1.33 0.47
Cliniciantimetoreview(minutes)

<1

Kroenke, J Gen Intern Med, 2001

* Lowe, J Affective Disorders, 2004

Summary
AxisII(1992):Reliable,valid,andsufficientutilityforuseasa
screener
RevisedAxisIIforDC/TMD
~100itemsforcomprehensiveassessment
Integratedassessmentmodel
Startwithscreeners,escalatetofullinstrumentsets
UseofPHQ9asprimarydistressscreener
Socialdisabilityscreener:Tobedeveloped
Tailoredassessment
Identifypsychosocialyellowflagsfromhistoryofcomplaint,
integrateintodecisionmaking
Furtherdevelopments
Developadditionalaxes
Applyontologic principlestoAxisIIconstructs

Acknowledgments
MiamiConsensusWorkshop
ValidationProject
Generalmembers:GaryAnderson,Sharon
UniversityofMinnesota:Mansur
Ahmad,GaryAnderson,Quintin
Brooks,WernerCeusters,TerriCowley,Don
Anderson,MaryHaugan,Amanda
Denucci,MarkDrangsholt,DominicEttlin,
Jackson,PatLenton,JohnLook,Wei
Charly Gaul,Yoly Gonzalez,JeanPaulGoulet,
Pan,EricSchiffman,Feng Tai.
LarsHollender,Rigmor Jensen,JohnKusiak,
Antoon deLaat,Reny deLeeuw,ThomasList,
UniversityatBuffalo:LeslieGarfinkel,
FrankLobbezoo,JohnLook,BillMaixner,
Yoly Gonzalez,PatriciaJahn,Krishnan
Ambra Michelotti,GregMurray,DonNixdorf,
Kartha,SharonMichalovic,Richard
Sandro Palla,ArnePetersson,EricSchiffman,
Ohrbach,TheresaSpeers.
BarrySmith,PeterSvensson,Corine Visscher,
UniversityofWashington:SamDworkin,
JoannaZakrzewska.
JoanneHarman,LarsHollender,
Biobehavioral Workgroup:SamDworkin,Lou
KimberlyHuggins,LloydMancl,Julie
Goldberg,JenniferHaythornthwaite,Mike
Sage,KathyScott,EarlSommers,Jeff
John,Marylee vander Meulen,Richard
Sherman,JudyTurner,Edmond
Ohrbach,PaulPincion.
Truelove.
InternationalRDC/TMDConsortiumNetwork
NIH/NIDCR U01DE013331
IASPOrofacialPainSIG
JORCOREDisabilityWorkgroup:Justin
CanadianInstituteforHealthResearch
Durham,Anat Gavish,Jordi Martinez
NationalCenterforBiomedicalOntology
Gomis,RichardOhrbach,Yoshihiro
Tsukiyama,Wataru Tachida.
Medtech

RDC/TMD and DC/TMD 2010: where are we

and where to we go from here?
Mark Drangsholt DDS, PhD
Oral Medicine/Dental Public Health Sciences
School of Dentistry
University of Washington
Seattle, WA, USA
July 16, 2010

What are the overall objectives of diagnosis?

Detecting or excluding disorders

Contributing to further diagnostic or therapeutic
management
Assessing prognosis
Monitoring clinical course
Measuring general health or fitness

Knotterus, 2003

What are the overall objectives of diagnosis in

TMD pain?

Detecting or excluding disorders Headache from TMD,

pulpitis from TMD?
Contributing to further diagnostic or therapeutic
management e.g. use NSAID or TCA medication?
Assessing prognosis pain likely to resolve or only
decrease somewhat?
Monitoring clinical course TMD pain improving,
declining, the same?
Measuring general health or fitness overall quality of
life of person

Overall model of diagnostic reference

standard
Reference standard

Questionnaire +

Examination

Diagnostic Tests

Increasing accuracy
Increasing burden of time, money, invasiveness

Overall model of diagnostic scheme

Increasing accuracy
Short
Questionnaire
Short
Questionnaire +

Short
Examination

Questionnaire +

Examination

Questionnaire

Examination

Diagnostic Tests

Increasing burden of time

cost,
Reference standard
invasiveness
Goal is to find the simplest, least invasive, least expensive & most accurate test

Phases of Therapeutic research

Study design

thousands

RCT

RCT

Phase I safety, dosing in humans hundreds

Phase II Tx in ideal circumstances
tens
Phase III Tx in usual circumstances

Phase IV Tx in routine practice

Controlled Trial

Case - Reports

ones

Numbers of studies

Phases of Diagnostic research

thousands

Cross-Sect Phase I Dx factor in patients, normals

hundreds

Case-Con

Cohort

Phase II Dx in ideal circumstances

Phase III Dx in usual circumstances

RCT

Phase IV Value of Dx in routine practice

Study design

tens
ones

Numbers of studies

Using DC-TMD in usual clinical settings is next step

Oxford levels of evidence applied to TMD

diagnosis
1985 level 5- expert opinions
1992 level 4 case-series, cross-sectional
2009 - level 3 large scale, multi-site case-control
2015? level 2 cohort?

Key to progress in diagnosis is understanding

underlying mechanisms in clinical patients
Heart rhythm problems from symptoms and
signs, EKG to mapping electrophysiologic
currents
Neoplasms from describing tumors, describing
histology, to biomarker predictors
TMD pain from signs and symptoms to
understanding the neural mechanisms - CNS

Thank you for your kind attention