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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, DDS, MS Aims: The original Research D...

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, DDS, MS Aims: The original Research Diagnostic Criteria for Temporomandibular Disorders Richard Ohrbach, DDS, PhD (RDC/TMD) Axis I diagnostic algorithms have been demonstrated to be reliable. Edmond Truelove, DDS, MSD However, the Validation Project determined that the RDC/TMD Axis I validity was John Look, DDS, PhD below the target sensitivity of ≥ 0.70 and specificity of ≥ 0.95. Consequently, these Gary Anderson, DDS, MS empirical results supported the development of revised RDC/TMD Axis I diagnostic Jean-Paul Goulet, DDS, MSD algorithms that were subsequently demonstrated to be valid for the most common Thomas List, DDS, Odont Dr pain-related TMD and for one temporomandibular joint (TMJ) intra-articular disorder. Peter Svensson, DDS, PhD, Dr Odont The original RDC/TMD Axis II instruments were shown to be both reliable and valid. Yoly Gonzalez, DDS, MS, MPH Working from these findings and revisions, two international consensus workshops Frank Lobbezoo, DDS, PhD were convened, from which recommendations were obtained for the finalization of Ambra Michelotti, DDS new Axis I diagnostic algorithms and new Axis II instruments. Methods: Through Sharon L. Brooks, DDS, MS a series of workshops and symposia, a panel of clinical and basic science pain Werner Ceusters, MD experts modified the revised RDC/TMD Axis I algorithms by using comprehensive Mark Drangsholt, DDS, PhD searches of published TMD diagnostic literature followed by review and consensus Dominik Ettlin, MD, DDS via a formal structured process. The panel’s recommendations for further revision Charly Gaul, MD of the Axis I diagnostic algorithms were assessed for validity by using the Validation Louis J. Goldberg, DDS, PhD 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 Jennifer A. Haythornthwaite, PhD instruments were identified through a comprehensive search of the literature Lars Hollender, DDS, Odont Dr providing valid instruments that, relative to the RDC/TMD, are shorter in length, Rigmor Jensen, MD, PhD are available in the public domain, and currently are being used in medical settings. Mike T. John, DDS, PhD Results: The newly recommended Diagnostic Criteria for TMD (DC/TMD) Antoon De Laat, DDS, PhD Axis I protocol includes both a valid screener for detecting any pain-related TMD Reny de Leeuw, DDS, PhD as well as valid diagnostic criteria for differentiating the most common pain-related William Maixner, DDS, PhD TMD (sensitivity ≥ 0.86, specificity ≥ 0.98) and for one intra-articular disorder Marylee van der Meulen, PhD (sensitivity of 0.80 and specificity of 0.97). Diagnostic criteria for other common Greg M. Murray, MDS, PhD intra-articular disorders lack adequate validity for clinical diagnoses but can be Donald R. Nixdorf, DDS, MS used for screening purposes. Inter-examiner reliability for the clinical assessment Sandro Palla, Dr Med Dent associated with the validated DC/TMD criteria for pain-related TMD is excellent Arne Petersson, DDS, Odont Dr (kappa ≥ 0.85). Finally, a comprehensive classification system that includes Paul Pionchon, DDS, PhD both the common and less common TMD is also presented. The Axis II protocol Barry Smith, PhD retains selected original RDC/TMD screening instruments augmented with new Corine M. Visscher, PT, PhD instruments to assess jaw function as well as behavioral and additional psychosocial Joanna Zakrzewska, MD, FDSRCSI factors. The Axis II protocol is divided into screening and comprehensive self- Samuel F. Dworkin, DDS, PhD report instrument sets. The screening instruments' 41 questions assess pain Author affiliations are listed at the end of this article. intensity, pain-related disability, psychological distress, jaw functional limitations, and parafunctional behaviors, and a pain drawing is used to assess locations of Correspondence to: pain. The comprehensive instruments, composed of 81 questions, assess in further Dr Eric Schiffman detail jaw functional limitations and psychological distress as well as additional Department of Diagnostic and constructs of anxiety and presence of comorbid pain conditions. Conclusion: The Biological Sciences recommended evidence-based new DC/TMD protocol is appropriate for use in both 6-320 Moos Tower clinical and research settings. More comprehensive instruments augment short and School of Dentistry simple screening instruments for Axis I and Axis II. These validated instruments University of Minnesota Minneapolis, MN, USA 55455 allow for identification of patients with a range of simple to complex TMD Fax: (612) 626-0138 presentations. J Oral Facial Pain Headache 2014;28:6–27. doi: 10.11607/jop.1151 Email: [email protected] *International Association for Dental Research. Key words: d  iagnostic criteria, diagnostic reliability, diagnostic validity, sensitivity, †International Association for the Study of Pain. specificity, temporomandibular disorders 6 Volume 28, Number 1, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.  Schiffman et al T emporomandibular disorders (TMD) are a sig- The RDC/TMD (1992) was intended to be only nificant public health problem affecting approx- a first step toward improved TMD classification, and imately 5% to 12% of the population.1 TMD is the authors stated the need for future investigation the second most common musculoskeletal condition of the accuracy of the Axis I diagnostic algorithms (after chronic low back pain) resulting in pain and dis- in terms of reliability and criterion validity—the lat- ability.1 Pain-related TMD can impact the individual’s ter involving the use of credible reference standard daily activities, psychosocial functioning, and quality diagnoses. Also recommended was further assess- of life. Overall, the annual TMD management cost in ment of the clinical utility of the Axis II instruments. the USA, not including imaging, has doubled in the The original RDC/TMD Axis I physical diagnoses last decade to $4 billion.1 have content validity based on the critical review by Patients often seek consultation with dentists experts of the published diagnostic approach in use for their TMD, especially for pain-related TMD. at that time and were tested using population-based Diagnostic criteria for TMD with simple, clear, reliable, epidemiologic data.6 Subsequently, a multicenter and valid operational definitions for the history, exami- study showed that, for the most common TMD, the nation, and imaging procedures are needed to render original RDC/TMD diagnoses exhibited sufficient re- physical diagnoses in both clinical and research set- liability for clinical use.7 While the validity of the in- tings. In addition, biobehavioral assessment of pain- dividual RDC/TMD diagnoses has been extensively related behavior and psychosocial functioning—an investigated, assessment of the criterion validity for essential part of the diagnostic process—is required the complete spectrum of RDC/TMD diagnoses had and provides the minimal information whereby one been absent until recently.8 can determine whether the patient’s pain disorder, For the original RDC/TMD Axis II instruments, especially when chronic, warrants further multidisci- good evidence for their reliability and validity for mea- plinary assessment. Taken together, a new dual-axis suring psychosocial status and pain-related disability Diagnostic Criteria for TMD (DC/TMD) will provide already existed when the classification system was evidence-based criteria for the clinician to use when published.9–13 Subsequently, a variety of studies have assessing patients, and will facilitate communication demonstrated the significance and utility of the original regarding consultations, referrals, and prognosis.2 RDC/TMD biobehavioral measures in such areas as The research community benefits from the ability predicting outcomes of clinical trials, escalation from to use well-defined and clinically relevant character- acute to chronic pain, and experimental laboratory set- istics associated with the phenotype in order to fa- tings.14–20 Other studies have shown that the original cilitate more generalizable research. When clinicians RDC/TMD biobehavioral measures are incomplete in and researchers use the same criteria, taxonomy, and terms of prediction of disease course.21–23 The overall nomenclature, then clinical questions and experience utility of the biobehavioral measures in routine clinical can be more easily transferred into relevant research settings has, however, yet to be demonstrated, in part questions, and research findings are more accessi- because most studies have to date focused on Axis I ble to clinicians to better diagnose and manage their diagnoses rather than Axis II biobehavioral factors.24 patients. The aims of this article are to present the evi- The Research Diagnostic Criteria for Temporo­ dence-based new Axis I and Axis II DC/TMD to be mandibular Disorders (RDC/TMD) have been the used in both clinical and research settings, as well as most widely employed diagnostic protocol for TMD present the processes related to their development. research since its publication in 1992.3 This classi- fication system was based on the biopsychosocial model of pain4 that included an Axis I physical as- Materials and Methods sessment, using reliable and well-operationalized diagnostic criteria, and an Axis II assessment of The RDC/TMD (Axis I and Axis II) was a model sys- psychosocial status and pain-related disability. The tem when it was published in 1992, but the authors intent was to simultaneously provide a physical di- recognized that it was only a beginning and that fur- agnosis and identify other relevant characteristics of ther research was needed to improve its validity and the patient that could influence the expression and clinical utility. Table 1 summarizes the subsequent thus management of their TMD. Indeed, the longer major steps from the RDC/TMD to the new DC/TMD. the pain persists, the greater the potential for emer- Specifically, in 2001, the National Institute of Dental gence and amplification of cognitive, psychosocial, and Craniofacial Research (NIDCR) in the USA, rec- and behavioral risk factors, with resultant enhanced ognizing the need to rigorously assess the diagnos- pain sensitivity, greater likelihood of additional pain tic accuracy of the dual-axis RDC/TMD, funded the persistence, and reduced probability of success from multisite Validation Project that resulted in a dataset standard treatments.5 of 705 participants who were classified, based on Journal of Oral & Facial Pain and Headache 7 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. Schiffman et al Table 1   Major Steps from the RDC/TMD* (1992) to the New DC/TMD† Year Event 1992 Publication of RDC/TMD Expert-based classification of most common TMD derived from epidemiologic and clinical data Dual-axis system: Clinical conditions (Axis I) and pain-related disability and psychological status (Axis II) 2001–2008 Validation Project Multicenter study with reference standard examiners Comprehensive assessment of the reliability and validity of the RDC/TMD Establish need to revise RDC/TMD 2008 Symposium at IADR‡ Conference (Toronto) Revised RDC/TMD diagnostic algorithms presented to the international research community Published critique and recommendations to enhance use in research 2009 International RDC/TMD Consensus Workshop at IADR Conference (Miami) Input from the international dental and medical clinical and research community as well as from patient advocate perspective Published critique and recommendations to facilitate use in clinical and research settings 2010 Publication of Major Findings by Validation Project Revised RDC/TMD algorithms provided reliable and valid clinical criteria for pain-related TMD Demonstrated need for imaging for most TMJ disc displacements and degenerative joint disease Support for existing Axis II instruments Recommended development of DC/TMD with international input 2010 Symposium at IADR Conference (Barcelona) DC/TMD presented to the international clinical and research community Critique and comments on Axis I diagnostic algorithms for the most common TMD and Axis II assessment protocol 2011 International RDC/TMD Consensus Workshop at IADR Conference (San Diego) Refinement of Axis I diagnostic algorithms for common and less common TMD 2011–2012 Field Trials of Axis I Examiner Specifications and Axis I & II Self-Report Instruments Test sites: Buffalo (US), Minneapolis (US), Malmö (Sweden), Aarhus (Denmark), Heidelberg (Germany), and Stockholm (Sweden) 2012 Finalization of DC/TMD at IADR Conference (Iguacu Falls) Further input from members of national and international TMD pain organizations Review of the DC/TMD by the IADR 2009 conference participants 2013 Final Estimates of Reliability and Validity for Axis I Diagnostic Criteria Derived from the datasets of the Validation Project and TMJ Impact Project Finalization of DC/TMD * Research Diagnostic Criteria for Temporomandibular Disorders. † Diagnostic Criteria for Temporomandibular Disorders. ‡ International Association for Dental Research. reference standard diagnoses, into 614 TMD cases displacements (DD) and for degenerative joint dis- and 91 controls.25 A description of the study meth- ease (DJD). Original RDC/TMD Axis II instruments ods as well as the demographics and clinical char- were shown to be reliable and valid for screening for acteristics of the sample are available.25–27 Reference psychosocial distress and pain-related disability, but standard diagnoses were established by consensus revision was warranted for both increased scope and between two TMD and orofacial pain experts at each improved clinical efficiency.28,29 of three study sites using a comprehensive history, In July 2008, the International RDC/TMD Consortium physical examination, and imaging studies (panoram- Network sponsored a symposium at the International ic radiograph, bilateral temporomandibular joint [TMJ] Association for Dental Research (IADR) Conference magnetic resonance imaging [MRI], and computed in Toronto entitled “Validation Studies of the RDC/ tomography [CT]). Acceptable validity was defined a TMD: Progress Towards Version 2.”30 Presentation priori as sensitivity ≥ 0.70 and specificity ≥ 0.95.3 of the revised RDC/TMD Axis I diagnostic algorithms When the original RDC/TMD Axis I TMD diagnoses and Axis II findings by the Validation Project’s key in- were compared to these reference standard diagno- vestigators was followed by critiques from researchers ses, the findings supported the need for revision of in the areas of radiology, neurology, pain psychology, these Axis I TMD diagnostic algorithms to improve and TMD and orofacial pain.31–36 A mandate emerged their diagnostic accuracy.8 The Validation Project sub- from the symposium in support of holding a consensus sequently developed and validated revised RDC/TMD workshop for the development of a new DC/TMD. Axis I diagnostic algorithms for myofascial pain and In March 2009, the International RDC/TMD arthralgia that have excellent diagnostic accuracy.27 Consortium Network (IADR) and the Orofacial However, revised diagnostic algorithms alone, with- Pain Special Interest Group (of the International out recourse to TMJ imaging, were still inadequate Association for the Study of Pain [IASP]) organized the for valid diagnoses of two of the three types of disc “International Consensus Workshop: Convergence on 8 Volume 28, Number 1, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.  Schiffman et al an Orofacial Pain Taxonomy” at the IADR Conference study. Generalized estimating equations (GEE) were in Miami to address the recommendations from both employed for validity and reliability estimates across the Validation Project investigators29 and the 2008 multiple examiners as well as adjustment of variance Toronto meeting regarding development of the new estimates for correlated data within patients. For the DC/TMD. The Validation Project’s findings and rec- Axis II portion of the new DC/TMD, the implementation ommendations, as well as comprehensive literature of the consensus report from the 2009 Miami work- searches regarding diagnostic tests, served as the shop was further refined based on recommendations basis for the resulting consensus-based recommen- from a subsequent workshop41 and recommendations dations that are available in the executive summary.37,38 from a recent publication that built upon Validation An ad-hoc Taxonomy Committee was appointed by Project findings.28 the workshop participants and charged with finalizing the workshop recommendations; these recommenda- tions were then reviewed by the workshop participants Results for feedback and approval. The Validation Project’s findings and recommendations were subsequently Overview published in 2010.8,25–29 The following recommendations represent an In July 2010, the working draft of the new DC/ evidence-­based new DC/TMD intended for immedi- TMD was presented to the international clinical and ate implementation in clinical and research settings. research community for critique and comments at a The 12 common TMD include arthralgia, myalgia, local symposium at the IADR Conference in Barcelona, myalgia, myofascial pain, myofascial pain with referral, Spain. Further refinement of select new DC/TMD di- four disc displacement disorders, degenerative joint agnoses occurred in 2011 at the "International RDC/ disease, subluxation, and headache attributed to TMD. TMD Consensus Workshop" at the IADR Conference The diagnostic algorithms with established estimates in San Diego. From 2011 to 2012, the examiner spec- of sensitivity and specificity for the most common TMD ifications for the Axis I assessment protocol and the are presented in Tables 2 and 3. Acceptable sensitiv- Axis II instruments were field tested. In 2012, the new ity and specificity for a definitive diagnosis are con- DC/TMD manuscript was then reviewed and finalized sidered as sensitivity ≥ 70% and specificity ≥ 95%.3 by the Miami 2009 workshop participants for publica- Diagnostic criteria with lower target sensitivity or tion. Detailed information regarding the development specificity, or having only content validity, were used of the new DC/TMD is available on the International when there was no available alternative. Decision trees RDC/TMD Consortium Network website.39 are available that map the patient history responses Concurrent with the above activities was the and clinical findings to these specific disorders except development of a new taxonomic classification for subluxation.42 Table 4 provides an expanded tax- structure. The Taxonomy Committee and selected onomic classification structure for both common and members of the 2009 workshop used the taxonom- less common TMD. The diagnostic criteria for these ic structures developed by the American Academy less common TMD have content validity but have not of Orofacial Pain (AAOP)40 to develop the struc- been assessed for criterion validity.43 The diagnostic ture used in this manuscript. This more compre- criteria for the less common TMD represent revisions hensive taxonomic structure and related diagnostic of the AAOP’s diagnostic criteria that have been up- criteria were refined by members of the workshop dated in a joint effort by members of the International held in 2011 in San Diego, and at the "International RDC/TMD Consortium Network and the Orofacial Consensus Workshop: Expanded TMD Taxonomy for Pain Special Interest Group of the IASP. Rigorous Further Classification Research" in June 2012 at the assessment of these diagnostic criteria for their criteri- IADR Conference in Iguacu Falls, Brazil. The AAOP on validity remains to be accomplished. council endorsed this taxonomic structure in 2012. The new DC/TMD Axis II protocol has been ex- With each refinement of the DC/TMD algorithms, panded by adding new instruments to evaluate pain the Validation Project team used the available dataset behavior, psychological status, and psychosocial and reference standards from that project to docu- functioning. The inclusion of the biobehavioral do- ment new estimates of diagnostic validity. Each of main has been well accepted in the pain field over- these analyses was reviewed and approved by mem- all, and the specific inclusion of new DC/TMD Axis bers of the Taxonomy Committee. When the final Axis I II instruments has been recommended as a gener- diagnostic algorithms were established, the Validation al model for assessing any pain patient.44 Finally, a Project team also tested their inter-examiner reliabil- “stepped” assessment model is embedded in the ity by using examination data collected from 46 pa- new DC/TMD components, allowing the protocol to tients by the 6 examiners who are implementing the support assessment ranging from screening to com- TMJ Impact Project, the Validation Project's follow-up prehensive expert evaluation. Journal of Oral & Facial Pain and Headache 9 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. Schiffman et al Table 2   Diagnostic Criteria for the Most Common Pain-Related Temporomandibular Disorders Indicated history and exam criteria must be met for each diagnosis. Myalgia (ICD-9 729.1; ICD-10 M79.1)* Description Pain of muscle origin that is affected by jaw movement, function, or parafunction, and replication of this pain occurs with provocation testing of the masticatory muscles. History Positive for both of the following: 1. Pain** in the jaw, temple, in the ear, or in front of ear; AND 2. Pain modified with jaw movement, function or parafunction. Criteria Exam Positive for both of the following: 1. Confirmation† of pain location(s) in the temporalis or masseter muscle(s); AND 2. Report of familiar pain‡ in the temporalis or masseter muscle(s) with at least one of the following provocation tests: a. Palpation of the temporalis or masseter muscle(s); OR b. Maximum unassisted or assisted opening movement(s). Validity Sensitivity 0.90; Specificity 0.99 Comments The pain is not better accounted for by another pain diagnosis. Other masticatory muscles may be examined as dictated by clinical circumstances, but the sensitivity and specificity for this diagnosis based on these findings have not been established. Types of myalgia as differentiated by provocation testing with palpation: Local myalgia, myofascial pain, and myofascial pain with referral Local myalgia (ICD-9 729.1; ICD-10 M79.1) Description Pain of muscle origin as described for myalgia with localization of pain only at the site of palpation when using the myofascial examination protocol.47 History Positive for both of the following: 1. Pain** in the jaw, temple, in the ear, or in front of ear; AND 2. Pain modified with jaw movement, function, or parafunction. Criteria Exam Positive for all of the following: 1. Confirmation† of pain location(s) in the temporalis or masseter muscle(s); AND 2. Report of familiar pain‡ with palpation of the temporalis or masseter muscle(s); AND 3. Report of pain localized to the site of palpation. Validity Sensitivity and specificity have not been established. Comments The pain is not better accounted for by another pain diagnosis. Other masticatory muscles may be examined as dictated by clinical circumstances but the sensitivity and specificity for this diagnosis based on these findings have not been established. Myofascial pain (ICD-9 729.1; ICD-10 M79.1) Description Pain of muscle origin as described for myalgia with pain spreading beyond the site of palpation but within the boundary of the muscle when using the myofascial examination protocol.47 History Positive for both of the following: 1. Pain** in the jaw, temple, in the ear, or in front of ear; AND 2. Pain modified with jaw movement, function or parafunction. Criteria Exam Positive for all of the following: 1. Confirmation† of pain location(s) in the temporalis or masseter muscle(s); AND 2. Report of familiar pain‡ with palpation of the temporalis or masseter muscle(s); AND 3. Report of pain spreading beyond the site of palpation but within the boundary of the muscle. Validity Sensitivity and specificity have not been established. Comments The pain is not better accounted for by another pain diagnosis. Other masticatory muscles may be examined as dictated by clinical circumstances but the sensitivity and specificity for this diagnosis based on these findings have not been established. Myofascial pain with referral (ICD-9 729.1; ICD-10 M79.1) Description Pain of muscle origin as described for myalgia with referral of pain beyond the boundary of the muscle being palpated when using the myofascial examination protocol.47 Spreading pain may also be present. History Positive for both of the following: 1. Pain** in the jaw, temple, ear, or in front of ear; AND 2. Pain modified with jaw movement, function, or parafunction. Criteria Exam Positive for all of the following: 1. Confirmation† of pain location(s) in the temporalis or masseter muscle(s); AND 2. Report of familiar pain‡ with palpation of the temporalis or masseter muscle(s); AND 3. Report of pain at a site beyond the boundary of the muscle being palpated. Validity Sensitivity 0.86; Specificity 0.98 Comments The pain is not better accounted for by another pain diagnosis. Other masticatory muscles may be examined as dictated by clinical circumstances but the sensitivity and specificity for this diagnosis based on these findings have not been established. 10 Volume 28, Number 1, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.  Schiffman et al Table 2   continued Arthralgia (ICD-9 524.62; ICD-10 M26.62) Description Pain of joint origin that is affected by jaw movement, function, or parafunction, and replication of this pain occurs with provocation testing of the TMJ. History Positive for both of the following: 1. Pain** in the jaw, temple, ear, or in front of ear; AND 2. Pain modified with jaw movement, function, or parafunction. Criteria Exam Positive for both of the following: 1. Confirmation† of pain location in the area of the TMJ(s); AND 2. Report of familiar pain‡ in the TMJ with at least one of the following provocation tests: a. Palpation of the lateral pole or around the lateral pole; OR b. Maximum unassisted or assisted opening, right or left lateral, or protrusive movement(s). Validity Sensitivity 0.89; Specificity 0.98 Comments The pain is not better accounted for by another pain diagnosis. Headache attributed to TMD (ICD-9 339.89 and 748.0; ICD-10 G44.89)§ Description Headache in the temple area secondary to pain-related TMD (see Note) that is affected by jaw movement, function, or parafunction, and replication of this headache occurs with provocation testing of the masticatory system. History Positive for both of the following: 1. Headache** of any type in the temple; AND 2. Headache modified with jaw movement, function, or parafunction. Criteria Exam Positive for both of the following: 1. Confirmation† of headache location in the area of the temporalis muscle(s); AND 2. Report of familiar headache‡ in the temple area with at least one of the following provocation tests: a. Palpation of the temporalis muscle(s); OR b. Maximum unassisted or assisted opening, right or left lateral, or protrusive movement(s). Validity Sensitivity 0.89; Specificity 0.87 Comments The headache is not better accounted for by another headache diagnosis. Note A diagnosis of pain-related TMD (eg, myalgia or TMJ arthralgia) must be present and is established using valid diagnostic criteria. * ICD-9: International Classification of Diseases 9th Revision; ICD-10: International Classification of Diseases 10th Revision. **The time frame for assessing pain including headache is in “the last 30 days” since the stated sensitivity and specificity of these criteria were established using this time frame. Although the specific time frame can be dependent on the context in which the pain complaint is being assessed, the validity of this diagnosis based on different time frames has not been established. † The examiner must identify with the patient all anatomical locations that they have experienced pain in the last 30 days. For a given diagnosis, the loca- tion of pain induced by the specified provocation test(s) must be in an anatomical structure consistent with that diagnosis. ‡ “ Familiar pain” or “familiar headache” is based on patient report that the pain induced by the specified provocation test(s) has replicated the pain that the patient has experienced in the time frame of interest, which is usually the last 30 days. “Familiar pain” is pain that is similar or like the patient’s pain complaint. “Familiar headache” is pain that is similar or like the patient’s headache complaint. § The ICD-9 and ICD-10 have not established a specific code for headache attributed to TMD as a secondary headache; ICD-9 339.89 and ICD-10 G44.89 are for “other headache syndrome” and ICD-9 784.0 is for "Headache, Facial Pain, Pain in Head NOS (Non-specific)." Workshop Recommendations for Axis I are summarized in Table 5. In the new DC/TMD, Pain-Related TMD Diagnoses myalgia represents what was called myofascial pain in the RDC/TMD. The term myofascial pain 1. The Axis I TMD Pain Screener45 is a simple, re- now describes two new DC/TMD diagnoses: liable, and valid self-report instrument used to myofascial pain and myofascial pain with refer- assess for the presence of any pain-related ral. Further detail regarding these changes can TMD, with sensitivity and specificity ≥ 0.95.46 be found in the Examination Specifications.47 For screening for pain-related TMD, the full six- The diagnostic algorithms in the new DC/TMD item version has sufficient reliability for assessing for arthralgia and myalgia now include criteria for individuals, such as in a clinical setting, whereas modification of pain by function, movement, or a three-item version is suitable for assessment of parafunction; these criteria are also included in the a population in research settings. The DC/TMD TMD Pain Screener. The clinical examination in- Symptom Questionnaire (DC/TMD SQ) provides cludes provocation tests for TMJ arthralgia of pain the necessary history for rendering a specific diag- with any jaw movement (ie, opening, lateral, and nosis in conjunction with the new DC/TMD pain- protrusive) and TMJ palpation. For myalgia, the related diagnostic algorithms. tests include pain with opening jaw movements 2. The changes in the diagnostic procedures for the and palpation of the temporalis and masseter pain diagnoses in the new DC/TMD, as compared muscles. Pain from these provocation tests must to the corresponding disorders in the RDC/TMD, replicate the patient’s pain complaint. Journal of Oral & Facial Pain and Headache 11 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. Schiffman et al Table 3   Diagnostic Criteria for the Most Common Intra-articular Temporomandibular Disorders Indicated history and exam criteria must be met for each diagnosis except subluxation, which is based only on history. Disc displacement with reduction (ICD-9 524.63; ICD-10 M26.63)* Description An intracapsular biomechanical disorder involving the condyle-disc complex. In the closed mouth position, the disc is in an anterior position relative to the condylar head and the disc reduces upon opening of the mouth. Medial and lateral displacement of the disc may also be present. Clicking, popping, or snapping noises may occur with disc reduction. A history of prior locking in the closed position coupled with interference in mastication precludes this diagnosis. History Positive for at least one of the following: 1. In the last 30 days,** any TMJ noise(s) present with jaw movement or function; OR 2. Patient report of any noise present during the exam. Exam Positive for at least one of the following: Criteria 1. Clicking, popping, and/or snapping noise during both opening and closing movements, detected with palpation during at least one of three repetitions of jaw opening and closing movements; OR 2a. Clicking, popping, and/or snapping noise detected with palpation during at least one of three repetitions of opening or closing movement(s); AND 2b. Clicking, popping, and/or snapping noise detected with palpation during at least one of three repetitions of right or left lateral, or protrusive movement(s). Validity Without imaging: sensitivity 0.34; specificity 0.92. Imaging is the reference standard for this diagnosis. Imaging When this diagnosis needs to be confirmed, TMJ MRI criteria 2 are positive for both of the following: 1. In the maximum intercuspal position, the posterior band of the disc is located anterior to the 11:30 position and the intermediate zone of the disc is anterior to the condylar head; AND 2. On full opening, the intermediate zone of the disc is located between the condylar head and the articular eminence. Disc displacement with reduction with intermittent locking (ICD-9 524.63; ICD-10 M26.63) Description An intracapsular biomechanical disorder involving the condyle-disc complex. In the closed mouth position, the disc is in an anterior position relative to the condylar head, and the disc intermittently reduces with opening of the mouth. When the disc does not reduce with opening of the mouth, intermittent limited mandibular opening occurs. When limited opening occurs, a maneuver may be needed to unlock the TMJ. Medial and lateral displacement of the disc may also be present. Clicking, popping, or snapping noises may occur with disc reduction. History Positive for both of the following: 1a. In the last 30 days,** any TMJ noise(s) present with jaw movement or function; OR 1b. Patient report of any noise present during the exam; AND 2. In the last 30 days,** jaw locks with limited mouth opening, even for a moment, and then unlocks. Criteria Exam Positive for at least one of the following: 1. Clicking, popping, and/or snapping noise detected during both opening and closing movements, detected with palpation during at least one of three repetitions of jaw opening and closing movements; OR 2a. Clicking, popping, and/or snapping noise detected with palpation during at least one of three repetitions of opening or closing movement(s); AND 2b. Clicking, popping, and/or snapping noise detected with palpation during at least one of three repetitions of right or left lateral, or protrusive movement(s). Validity Without imaging: sensitivity 0.38; specificity 0.98. Imaging is the reference standard for this diagnosis. Imaging When this diagnosis needs to be confirmed, the imaging criteria 2 are the same as for disc displacement with reduction if intermittent locking is not present at the time of imaging. If locking occurs during imaging, an imaging- based diagnosis of disc displacement without reduction will be rendered and clinical confirmation of reversion to intermittent locking is needed. Note Although not required, when this disorder is present clinically, examination is positive for inability to open to a normal amount, even momentarily, without the clinician or patient performing a maneuver to reduce the lock. Disc displacement without reduction with limited opening (ICD-9 524.63; ICD-10 M26.63) Description An intracapsular biomechanical disorder involving the condyle-disc complex. In the closed mouth position, the disc is in an anterior position relative to the condylar head, and the disc does not reduce with opening of the mouth. Medial and lateral displacement of the disc may also be present. This disorder is associated with persistent limited mandibular opening that does not reduce with the clinician or patient performing a manipulative maneuver. This is also referred to as “closed lock.” This disorder is associated with limited mandibular opening. History Positive for both of the following: 1. Jaw locked so that the mouth would not open all the way; AND Criteria 2. Limitation in jaw opening severe enough to limit jaw opening and interfere with ability to eat. Exam Positive for the following: 1. Maximum assisted opening (passive stretch) movement including vertical incisal overlap < 40 mm. Validity Without imaging: sensitivity 0.80; specificity 0.97. Imaging is the reference standard for this diagnosis. Imaging When this diagnosis needs to be confirmed, TMJ MRI criteria 2 are positive for both of the following: 1. In the maximum intercuspal position, the posterior band of the disc is located anterior to the 11:30 position and the intermediate zone of the disc is anterior to the condylar head, AND 2. On full opening, the intermediate zone of the disc is located anterior to the condylar head. Note: Maximum assisted opening of < 40 mm is determined clinically. Note Presence of TMJ noise (eg, click during opening) does not exclude this diagnosis. 12 Volume 28, Number 1, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.  Schiffman et al Table 3   continued Disc displacement without reduction without limited opening (ICD-9 524.63; ICD-10 M26.63) Description An intracapsular biomechanical disorder involving the condyle-disc complex. In the closed mouth position, the disc is in an anterior position relative the condylar head and the disc does not reduce with opening of the mouth. Medial and lateral displacement of the disc may also be present. This disorder is NOT associated with current limited opening. History Positive for both of the following in the past: 1. Jaw locked so that the mouth would not open all the way; AND Criteria 2. Limitation in jaw opening severe enough to limit jaw opening and interfere with ability to eat. Exam Positive for the following: 1. Maximum assisted opening (passive stretch) movement including vertical incisal overlap ≥ 40 mm. Validity Without imaging: sensitivity 0.54; specificity 0.79. Imaging is the reference standard for this diagnosis. Imaging When this diagnosis needs to be confirmed, TMJ MRI criteria 2 are the same as for disc displacement without reduction with limited opening. Note: Maximum assisted opening of ≥ 40 mm is determined clinically. Note Presence of TMJ noise (eg, click during opening) does not exclude this diagnosis. Degenerative joint disease (ICD-9 715.18; ICD-10 M19.91) Description A degenerative disorder involving the joint characterized by deterioration of articular tissue with concomitant osseous changes in the condyle and/or articular eminence. History Positive for at least one of the following: 1. In the last 30 days,** any TMJ noise(s) present with jaw movement or function; OR Criteria 2. Patient report of any noise present during the exam. Exam Positive for the following: 1. Crepitus detected with palpation during at least one of the following: opening, closing, right or left lateral, or protrusive movement(s). Validity Without imaging: sensitivity 0.55; specificity 0.61. Imaging is the reference standard for this diagnosis. Imaging When this diagnosis needs to be confirmed, then TMJ CT criteria106 are positive for at least one of the following: Subchondral cyst(s), erosion(s), generalized sclerosis, or osteophyte(s). Note: Flattening and/or cortical sclerosis are considered indeterminant findings for degenerative joint disease (DJD) and may represent normal variation, aging, remodeling, or a precursor to frank DJD. Subluxation (ICD-9 830.1; ICD-10 SO3.OXXA) Description A hypermobility disorder involving the disc-condyle complex and the articular eminence: In the open mouth position, the disc-condyle complex is positioned anterior to the articular eminence and is unable to return to a normal closed mouth position without a manipulative maneuver. The duration of dislocation may be momentary or prolonged. When the patient can reduce the dislocation himself/herself, this is referred to as subluxation. When the patient needs the assistance of the clinician to reduce the dislocation and normalize jaw movement, this is referred to as luxation. This disorder is also referred to as “open lock.” The sensitivity and specificity have been established for only subluxation. History Positive for both of the following: 1. In last 30 days,** jaw locking or catching in a wide open mouth position, even for a moment, so could not close from Criteria the wide-open position; AND 2. Inability to close the mouth from a wide-open position without a self-maneuver. Exam Although no exam findings are required, when this disorder is present clinically, examination is positive for inability to return to a normal closed mouth position without the patient performing a manipulative maneuver. Validity Without imaging and based only on history: sensitivity 0.98; specificity 1.00. Imaging When this diagnosis needs to be confirmed, imaging criteria are positive for the condyle positioned beyond the height of the articular eminence with the patient unable to close his/her mouth. *ICD-9: International Classification of Diseases 9th Revision; ICD-10: International Classification of Diseases 10th Revision. **The time frame for assessing selected biomechanical intra-articular disorders is in “the last 30 days” since the stated sensitivity and specificity of these criteria were established using this time frame. Although the specific time frame can be dependent on the context in which the noise or biomechanical complaints are being assessed, the validity of this diagnosis based on different time frames has not been established. 3. The disorder of myofascial pain with limited open- the boundary of the muscle being palpated; and ing, as described in the RDC/TMD, is eliminated. (3) myofascial pain with referral, defined as pain 4. For the new DC/TMD, muscle pain diagno- at a site beyond the boundary of the muscle be- ses are organized into four major subclasses: ing palpated. The diagnostic criteria for myalgia myalgia, tendonitis, myositis, and spasm (see and one of its types, myofascial pain with refer- Table 4). Myalgia is further subdivided into three ral, have criterion validity and are listed in Table 2. mutually exclusive types of myalgia: (1) local The palpation pressure for myalgia is 1 kg for myalgia, defined as pain localized to the site of 2 seconds, but to differentiate the three types palpation; (2) myofascial pain, defined as pain of myalgia, the duration of the 1 kg of palpation spreading beyond the site of palpation but within pressure is increased to 5 seconds to allow more Journal of Oral & Facial Pain and Headache 13 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. Schiffman et al Table 4  Taxonomic Classification for Table 5  From RDC/TMD to DC/TMD: Temporomandibular Disorders Comparison of Diagnostic Procedures for Pain-Related TMD I. TEMPOROMANDIBULAR JOINT DISORDERS 1. Joint pain RDC/ DC/ A. Arthralgia TMD TMD B. Arthritis 2. Joint disorders HISTORY (applicable to all pain-related TMD) A. Disc disorders Presence of masticatory system pain ✓ ✓ 1. Disc displacement with reduction Headache of any type in temporal region ✓ 2. Disc displacement with reduction with intermittent locking 3. Disc displacement without reduction with limited opening Pain or headache modification with jaw move- ✓ 4. Disc displacement without reduction without limited opening ment, function, or parafunction B. Hypomobility disorders other than disc disorders EXAMINATION 1. Adhesions/adherence Arthralgia 2. Ankylosis a. Fibrous Confirmation of location of pain in the joint ✓ b. Osseous Pain with joint palpation C. Hypermobility disorders Lateral pole ✓ ✓ 1. Dislocations Around lateral pole ✓ a. Subluxation Posterior site ✓ b. Luxation 3. Joint diseases Pain with range of motion ✓ ✓ A. Degenerative joint disease Familiar pain with palpation or range of motion ✓ 1. Osteoarthrosis Myalgia (“Myofascial pain” in RDC/TMD) 2. Osteoarthritis B. Systemic arthritides Confirmation of location of pain in a ✓ C. Condylysis/idiopathic condylar resorption masticatory muscle D. Osteochondritis dissecans Pain with muscle palpation (required sites) E. Ostronecrosis Temporalis ✓ ✓ F. Neoplasm Masseter ✓ ✓ G. Synovial chondromatosis Posterior mandibular region ✓ 4. Fractures Submandibular region ✓ 5. Congenital/developmental disorders Lateral pterygoid area ✓ A. Aplasia Temporalis tendon ✓ B. Hypoplasia Pain with maximum unassisted or ✓ C. Hyperplasia assisted opening II. MASTICATORY MUSCLE DISORDERS 1. Muscle pain Familiar pain with palpation or opening ✓ A. Myalgia Local myalgia (new diagnosis) 1. Local myalgia Sustained palpation with no identification of ✓ 2. Myofascial pain spreading pain or referral patterns 3. Myofascial pain with referral B. Tendonitis Myofascial pain (new diagnosis) C. Myositis Sustained palpation with identification of ✓ D. Spasm spreading pain but no referral patterns 2. Contracture Myofascial pain with referral (new diagnosis) 3. Hypertrophy Sustained palpation with identification of ✓ 4. Neoplasm referral patterns (spreading pain may also be 5. Movement disorders present) A. Orofacial dyskinesia B. Oromandibular dystonia Headache attributed to TMD (new diagnosis) 6. Masticatory muscle pain attributed to systemic/central Confirmation of location of headache in ✓ pain disorders temple area A. Fibromyalgia/widespread pain Familiar headache with palpation or range of ✓ III. HEADACHE motion 1. Headache attributed to TMD IV. ASSOCIATED STRUCTURES 1. Coronoid hyperplasia Table developed in collaboration with Peck and colleagues.43 time to elicit spreading or referred pain, if pres- then the more general diagnostic procedures as ent.47 The diagnostic criteria for local myalgia and described in Table 2 are sufficient. myo­fascial pain, which have content validity but for which criterion validity has not been estab- Workshop Recommendations for Axis I lished, are presented in Table 2 for completeness; TMJ Disc Displacement (DD) and their respective validity estimates will be posted Degenerative Joint Disease (DJD) on the Consortium website after they are estab- 1. The clinical procedures for assessing DD with lished.48 If a diagnosis of myalgia is desired, and reduction, DD without reduction without limit- no distinction between the three types is needed, ed opening, and DJD lead to clinical diagnoses 14 Volume 28, Number 1, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.  Schiffman et al based on procedures that exhibit low Table 6  From RDC/TMD to DC/TMD: sensitivity but good to excellent specific- Comparison of Diagnostic Procedures for ity. Consequently, for treatment decision- Disc Displacements and Degenerative making in selective cases, confirmation Joint Disease with New History-Based of a provisional clinical diagnosis requires Diagnosis of Subluxation imaging. In contrast, the clinical proce- RDC/ DC/ dures for assessing DD without reduc- TMD TMD tion with limited opening have acceptable HISTORY sensitivity and specificity, and the clinical “In last 30 days, any noise present” applicable to ✓ evaluation may be sufficient for the initial disc displacement with reduction with and without working diagnosis. intermittent locking, and degenerative joint disease 2. The changes made to the diagnostic pro- “In last 30 days, jaw locks with limited mouth opening ✓ cedures in the new DC/TMD for DD and and then unlocks” applicable to disc displacement with reduction with intermittent locking DJD as compared to the RDC/TMD are “Ever have jaw lock or catch so that it would not open ✓ ✓ summarized in Table 6. Further detail re- all the way” and "interfered with eating" applicable to garding these changes can be found in disc displacement without reduction with and without the Examination Specifications.47 TMJ limited opening noise by history is a recommended crite- “In last 30 days, when you opened your mouth wide, jaw ✓ locked or caught so that it would not close all the way” rion for the intra-articular disorders of DD applicable to subluxation with reduction and DJD. This history cri- EXAMINATION terion may be met by the patient’s report Disc displacement with reduction of any joint noise (click or crepitus) during Report by patient of any joint noise (click or crepitus) ✓ the 30 days prior to the examination, or by Click detection (# of opening/closing cycles required 2 of 3 1 of 3 for click) the patient’s detection of any joint noise Click detection during lateral and protrusive movements ✓ ✓ with jaw movements during the clinical ex- 5 mm vertical distance between reciprocal clicks ✓ amination. In addition, a diagnosis of DD Elimination of click in protrusive position ✓ with reduction requires examiner detection Disc displacement with reduction with intermittent locking ✓ of clicking, popping, or snapping noises Disc displacement without reduction with limited opening during the examination. Establishing a Unassisted opening* ≤ 35 mm and assisted opening ✓ diagnosis of DJD necessitates examiner ≤ 4 mm more than unassisted opening detection of crepitus (eg, crunching, grind- Assisted opening* < 40 mm ✓ Contralateral movements < 7 mm and/or uncorrected ✓ ing, or grating noises) during the examina- deviation to the ipsilateral side on opening tion. For DJD, no distinction between fine Absence of noise, or noise not meeting criteria for ✓ versus coarse crepitus is made. Finally, for disc displacement with reduction DD without reduction, an assisted open- Disc displacement without reduction without limited opening ing measurement (including the amount Unassisted opening* > 35 mm and assisted opening ✓ of vertical incisal overlap) of < 40 mm > 4 mm more than unassisted opening yields the subtype of “with limited open- Assisted opening* ≥ 40 mm ✓ ing,” while the measurement ≥ 40 mm Contralateral and protrusive movements ≥ 7 mm ✓ yields the subtype of “without limited Noise not meeting criteria for disc displacement with ✓ reduction opening,” and joint noises, if present, do Degenerative joint disease not affect the diagnosis of DD without re- Report by patient of any joint noise (click or crepitus) ✓ duction as long as the required criteria for Crepitus (only coarse) with palpation ✓ DD without reduction are met. Crepitus (either fine or coarse) with palpation ✓ 3. DD with reduction with intermittent lock- *Measurement of opening includes interincisal opening plus vertical ing and TMJ subluxation are included as incisal overlap. new disorders. The diagnostic algorithms for these disorders include specific criteria Workshop Recommendations for Axis I Headache from the patient history, including current Disorders intermittent locking with limited opening for “Headache attributed to TMD” is included as a new disor- DD with reduction with intermittent locking der type to replace “Headache or facial pain attributed to and jaw locking in the wide-open position temporomandibular joint (TMJ) disorder" as described in the for TMJ subluxation. International Classification of Headache Disorders II (ICHD- 4. Nomenclature change: The terms osteoar- 2).49 The diagnostic algorithm for headache attributed to thritis and osteoarthrosis are considered TMD has been previously published50 and has been incor- to denote subclasses of DJD. porated into the beta version of the ICHD-3 (See Table 5).51 Journal of Oral & Facial Pain and Headache 15 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. Schiffman et al Table 7   Recommended Axis II Assessment Protocol Domain Instrument No. of items Screening Comprehensive Pain intensity Graded Chronic Pain Scale (GCPS) 3 ✓ ✓ Pain locations Pain drawing 1 ✓ ✓ Physical function Graded Chronic Pain Scale (GCPS) 4 ✓ ✓ Limitation Jaw Functional Limitation Scale—short form (JFLS) 8 ✓ Jaw Functional Limitation Scale—long form (JFLS) 20 ✓ Distress Patient Health Questionnaire-4 (PHQ-4) 4† ✓ Depression Patient Health Questionnaire-9* (PHQ-9) 9† ✓ Anxiety Generalized Anxiety Disorder-7 (GAD-7) 7† ✓ Physical symptoms Patient Health Questionnaire-15* (PHQ-15) 15 ✓ Parafunction Oral Behaviors Checklist (OBC) 21 ✓ ✓ *The RDC/TMD depression and nonspecific physical symptoms instruments could be substituted for the PHQ-9 and PHQ-15, respectively, if continuity with legacy data is important. † Each of the PHQ-4, PHQ-9, and GAD-7 include one additional item beyond the number listed above; the additional item is a global reflective question regarding functional interference due to any of the endorsed symptoms on that instrument. Workshop Recommendations for Axis II disability rating, which is based on number of days Evaluation that pain interferes with activity and on extent of It is well recognized that patients’ cognitive, emo- interference with social, work, or usual daily activ- tional, and behavioral responses to pain are quite ities. High pain and high interference, or moder- independent of the source of their pain, so the ate to severe disability (classified as Grades 3 or workgroup recommended instruments current- 4), should be interpreted as disability due to pain, ly used in other areas of medicine to assess the warranting further investigation, and suggests psychosocial functioning associated with any pain that the individual is experiencing significant im- condition. In addition, the Jaw Functional Limitation pact from the TMD on his or her life. The third Scale (JFLS) was selected to assess jaw func- instrument is a pain drawing of the head, jaw, tion specific to TMD. The criteria used to select and body, and it allows the patient to report the the additional Axis II instruments were reliability, location of all pain complaints.54,55 Widespread validity, interpretability, patient and clinician accept- pain suggests the need for comprehensive as- ability, patient burden, and feasibility, as well as avail- sessment of the patient. The fourth instrument is ability of translated versions for different languages the reliable and valid short form (eight items) of and cultures. All areas of biopsychosocial assess- the JFLS that assesses global limitations across ment with the recommended instruments are avail- mastication, jaw mobility, and verbal and emotion- able from the Consortium52 and are summarized in al expression.56,57 The fifth instrument is the Oral Table 7. Behaviors Checklist (OBC), which assesses the 1. Axis II screeners. Five simple self-report screen- frequency of oral parafunctional behaviors.58,59 ing instruments are included for detection of pain- 2. Comprehensive Axis II instruments. The instru- relevant psychosocial and behavioral functioning. ments to be used when indicated by clinical The Patient Health Questionnaire-4 (PHQ-4) is specialists or researchers in order to obtain a a short, reliable, and valid screening instrument more comprehensive evaluation of psychosocial for detecting “psychological distress” due to anx- functioning are listed in Table 7 and follow the iety and/or depression in patients in any clinical Initiative on Methods, Measurement, and Pain setting.53 A cutoff of > 6, suggesting moderate Assessment in Clinic Trials (IMMPACT) recom- psychological stress, should be interpreted as mendations.60 Those recommendations include warranting observation, while a cutoff of > 9, assessment of pain intensity, physical functioning suggesting severe psychological distress, should (both general and disease-specific), and emo- be interpreted as warranting either further as- tional functioning. In addition to measuring pain sessment or referral.53 The Graded Chronic Pain intensity and pain disability (via GCPS, as de- Scale (GCPS) is a short, reliable, and valid instru- scribed previously) and disease-specific physical ment that assesses pain intensity and pain-re- functioning (via the 20-item version of the JFLS), lated disability.10 The two GCPS subscales are: the new DC/TMD includes new measures for a (1) Characteristic Pain Intensity (CPI), which re- more comprehensive assessment of emotional liably measures pain intensity, with ≥ 50/100 functioning. This assessment uses the PHQ-961 considered “high intensity,” and (2) the pain- for depression (with cutoffs of 5, 10, 15, and 20 16 Volume 28, Number 1, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.  Schiffman et al representing, respectively, mild, moderate, mod- Interexaminer Reliability of the Recommended erately severe, and severe levels of depression) DC/TMD Axis I Diagnostic Algorithms and Generalized Anxiety Disorder-7 (GAD-7)62 Interexaminer reliability of myalgia, as a patient-spe- for anxiety (with cutoffs of 10 and 15 represent- cific diagnosis, was demonstrated to be excellent, ing, respectively, moderate and severe levels of with kappa = 0.94 (0.83, 1.00), as was also myo- anxiety). Finally, like the RDC/TMD, the new DC/ fascial pain with referral, which had kappa = 0.85 TMD retains a measure for physical symptoms by (0.55, 1.00). GEE-based kappa estimates for the using the PHQ-1563 (with cutoffs of 5, 10, and 15 joint-specific diagnoses were computed using data representing, respectively, low, medium, and high from the TMJ Impact Project's examiner reliability as- somatic symptom severity) due to the overwhelm- sessments. Reliability for arthralgia was excellent, at ing importance of overall symptom reporting in kappa = 0.86 (0.75, 0.97). However, detection of in- individuals with TMD.64 The pain drawing and the tracapsular diagnoses, based only on clinical signs OBC are also components of the comprehensive and symptoms, was too low for most reliability esti- assessment. mates to be credible. This was due to the low preva- lence of these diagnoses in the convenience sample Data Collection Forms and Examination used for this reliability study. In addition, there were Specifications no cases of DD without reduction with limited open- A short, focused new DC/TMD Symptom Question­ ing (all measurements for vertical interincisal opening naire (DC/TMD SQ)65 was developed to assess pain were > 40 mm), and DD with reduction with intermit- characteristics as well as history of jaw noise, jaw tent locking was rare (4 of 92 TMJs). DD with reduc- locking, and headache. The DC/TMD SQ provides tion showed kappa = 0.58 (0.33, 0.84). DD without the necessary history for the Axis I diagnostic criteria. reduction without limited opening manifested an The new DC/TMD operational specifications for the excellent kappa of 0.84, although the confidence lim- clinical tests, examination forms, DC/TMD SQ, and its were wide (0.38, 1.00). The point estimate of ex- biobehavioral assessment instruments can be down- aminer agreement on DJD was kappa = 0.33 with a loaded from the Consortium website38 and used wide confidence interval (0.01, 0.65) associated with without copyright infringement. the low examiner detection rate for DJD; this diag- nosis was made by at least one examiner in only 20 Validity of the Newly Recommended TMJs during a total of 138 examinations performed in DC/TMD Axis I Diagnostic Algorithms 46 subjects. Also contributing to the low kappa point Sufficient data from the Validation Project existed to estimate was low examiner agreement on a finding of provide a credible estimate of the criterion validity crepitus, at kappa = 0.3 (0.00, 0.61). for myalgia as a class with sensitivity of 0.90 (95% confidence limits of 0.87 and 0.94) and specificity of 0.99 (0.97, 1.00). Myofascial pain with referral as Discussion a type of myalgia showed sensitivity of 0.86 (0.79, 0.94) and specificity of 0.98 (0.97, 0.99). Finally, ar- The new DC/TMD Axis I and Axis II are an evi- thralgia had sensitivity of 0.89 (0.84, 0.92) and spec- dence-based assessment protocol that can be im- ificity of 0.98 (0.95, 0.99). Among the intracapsular mediately implemented in the clinical and research diagnoses, excellent validity was confirmed for DD setting. Compared to the original RDC/TMD proto- without reduction with limited opening, with sensitiv- col,3 the new DC/TMD includes a valid and reliable ity of 0.80 (0.63, 0.90) and specificity of 0.97 (0.95, Axis I screening questionnaire for identifying pain- 0.98). The validity for the other disc displacements related TMD as well as valid and reliable Axis I was inadequate: DD with reduction had sensitivity of diagnostic algorithms for the most common pain- 0.34 (0.28, 0.41) and specificity of 0.92 (0.89, 0.94); related TMD as part of a comprehensive TMD taxo- DD with reduction with intermittent locking showed nomic classification structure. Diagnostic criteria for sensitivity of 0.38 (0.24, 0.54) and specificity of 0.98 all but one of the most common intra-articular disor- (0.96, 0.99); and disc displacement without reduc- ders lacked adequate validity for clinical diagnoses tion without limited opening exhibited sensitivity of but can be used for screening purposes. The nec- 0.54 (0.44, 0.62) and specificity of 0.79 (0.74, 0.83). essary information for fulfilling the Axis I diagnostic The sensitivity of the recommended clinical criteria criteria is collected from the specified examination for DJD was 0.55 (0.47, 0.62) and specificity was protocol in conjunction with the core self-report in- 0.61 (0.56, 0.65). The total width of all confidence struments that assess pain symptoms involving the intervals was < 0.20, except for disc displacement jaw, jaw noise and locking, and headache. Axis II with reduction with intermittent locking for which the core assessment instruments assess pain inten- total interval was 0.30. sity, pain disability, jaw functioning, psychosocial Journal of Oral & Facial Pain and Headache 17 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. Schiffman et al distress, parafunctional behaviors, and widespread familiar pain during jaw movement or from palpation pain. These changes in the core patient assessment of jaw structures such as muscle or joint. For ex- instrument set serve as a broad foundation for pa- ample, infection and rheumatoid disease affecting tient assessment and further research. The new DC/ the TMJ can result in the report of familiar pain from TMD includes important additions, deletions, and movement and/or palpation of the associated struc- modifications to the original RDC/TMD that deserve tures. In order for the criterion of familiar pain to lead comment. These changes are a result of research logically to the specified diagnosis, the signs must findings and expert contributions from professional explain the symptoms; the symptom history, or ad- clinical and research groups guided by the principle ditional assessment, must effectively rule out other to create a new parsimonious DC/TMD based on the competing diagnoses.75 best available evidence. This article cites the core as- For myalgia and the three types of myalgia diag- sessment instruments that existed at the time of this noses, palpation of only the temporalis and masse- publication, and these instruments will be updated as ter muscles is required; mandatory palpation of the indicated in the future with the most current versions temporalis tendon, lateral pterygoid area, subman- available on the Consortium website.38 dibular region, and posterior mandibular region has been eliminated because of poor reliability,76–78 and Features of the DC/TMD History and not examining these areas does not significantly Examination Protocol affect the validity of these diagnoses.27 For exam- The criterion for a patient report of pain modified— ple, the lateral pterygoid area is commonly tender that is, made better or worse—by jaw function, move- in non-cases, leading to false positives when the ment, or parafunction is now a requirement for all RDC/TMD are used.76 It is also uncommon for these pain-related TMD diagnoses; this feature is shared other sites to be painful to palpation when the mas- with other musculoskeletal pains.66,67 Questions re- seter or temporalis muscles are not, but they may be garding pain modification are integral to the history included as part of the examination when clinically and are derived from the TMD Pain Screener or from indicated or for specific research questions. For the the more comprehensive DC/TMD SQ that con- same reason, palpation of the posterior aspect of the tains all of the history questions required for the new TMJ through the external auditory meatus has also DC/TMD diagnostic algorithms.45,46,65 Pain modifica- been eliminated but can be used when indicated. tion is especially important in differential diagnosis in TMJ noises can be difficult to detect, even with a broader clinical setting when comorbid conditions auscultation using a stethoscope, and may be may be present, especially other pain conditions of sporadically present. In addition, the data of the the trigeminal system. Validation Project have demonstrated that patient The clinical provocation of “familiar pain” has differentiation of noises such as clicking, crunching, proved useful in the assessment of other orthopedic grinding, or grating noises (ie, crepitus) was an in- and pain disorders.68–74 The rationale is that the clini- consistent source of clinical information. Typically, cian needs to provoke the patient’s pain complaint in such information gathering requires reviewing these order for a positive examination response to be clin- noises with the patient and then carefully interpreting ically meaningful. A patient report of familiar pain is their responses. These data confirm the most reliable required with pain provoked by jaw movement and/ approach is based on patient detection of any such or palpation to diagnose all pain-related TMD, includ- noise within the last 30 days or patient detection of ing arthralgia, myalgia, the three types of myalgia, and any noise occurring with jaw movements during the headache attributed to TMD. Familiar pain is pain that clinical examination. Whether to use “last 30 days” is like or similar to the pain that the patient has been or a different period is addressed in the footnote in experiencing. The intent is to replicate the patient’s Table 3. The distinction between coarse and fine chief complaint of pain(s) in such a way that the pa- crepitus was omitted, as these sounds are not reli- tient describes the provoked pain in the same way— ably distinguished and the distinction does not con- because it is the same type of pain. This criterion tribute to the diagnostic accuracy of DJD. minimizes false-positive findings from pain-provoking tests in asymptomatic patients and incidental findings Changes to Original RDC/TMD Pain Diagnoses in symptomatic patients. Similarly, a report of "familiar The original RDC/TMD diagnosis of myofascial headache" is required from the examination as part pain with limited opening has not yet demonstrated of the diagnostic algorithm for “Headache attributed unique clinical utility and was eliminated in the new to TMD.” It must, however, be emphasized that the DC/TMD. The remaining original RDC/TMD diag- presence of familiar pain is not associated exclusive- nosis of myofascial pain has been reorganized in ly with the diagnoses of arthralgia, myalgia, and the the new DC/TMD into two new disorders with cri- three types of myalgia, as other conditions may cause terion validity: myalgia (as a subclass of muscle pain 18 Volume 28, Number 1, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.  Schiffman et al disorders) and myofascial pain with referral (as a type The low sensitivity for the diagnostic algorithms of myalgia); see Table 4. Although the diagnostic cri- for DD and DJD suggests these criteria be limited to teria for local myalgia and myofascial pain, as types of providing provisional diagnoses. For example, for a myalgia, have content validity, the criterion validity has diagnosis of DD with reduction, a positive history of not been established. Myofascial pain with referral is noise and the presence clinically of clicking noises a distinct clinical disorder with central convergence (as specified) effectively rules in the diagnosis due accounting for the referral of pain to other anatomi- to the high specificity of the criteria, while a nega- cal sites.79–81 Referred pain has clinical utility for, at a tive finding can be associated with false negatives minimum, differential diagnosis regarding the identifi- due to low sensitivity. Consequently, some DD with cation of pain in other anatomical locations, including reduction will not have clinically detectable noise or pain referred to the teeth that is shown ultimately to will have fewer clicks or different types of noise, and be pain of muscular origin. the disorder will not be diagnosed using the clinical “Headache attributed to TMD” is a new Axis I criteria.105 Based on available data, DD with reduc- diagnostic classification.82 Tension-type headache tion is highly prevalent and is probably without clinical (TTH) and migraine have been associated with consequence unless pain occurs with the noise, or TMD.19,83–90 In particular, TTH and TMD share many functional limitations such as limited opening or inter- symptoms,19,90,91 although this may not imply identical ference in mastication are present. Nevertheless, im- pathophysiology or underlying mechanisms.88,91,92 A aging using MRI is required for a definitive diagnosis subgroup of headache patients experience increased of TMJ DD, and CT imaging is required for a defini- headache following masticatory system overuse such tive diagnosis of DJD. The single diagnostic excep- as clenching of the teeth.88,89,92,93 Longitudinal stud- tion is DD without reduction with limited opening (ie, ies have found that the development of TMD was “closed lock”), which shows good diagnostic validity accompanied by an increase in headache and that without imaging (ie, sensitivity 80%; specificity 97%). the presence of TMD at baseline predicted the onset However, the criteria for DD without reduction with of headache.94,95 Finally, treatment of the masticatory limited opening have not been assessed in subjects system has also been associated with a report of de- with other causes of limited opening such as adhe- creased headaches.96–98 These findings suggest that sions, coronoid hyperplasia, or muscle contracture. some headaches may be secondary to TMD. The need for a definitive DD diagnosis, and thus the Frequency of TTH99 and migraine correlate with indication to use imaging, is based on whether the functional disability and are a useful patient charac- information gained will change the patient’s treatment terization,100–102 and increased frequency of head- plan or prognosis. Reliable imaging criteria for these aches in the temples is associated with increased disorders are available.106 symptoms of pain-related TMD.102 Future research will explore whether frequency of pain when used Taxonomic Classification Structure and to subclassify headache attributed to TMD, TMJ ar- Classification of the Less Common TMD thralgia, and TMD myalgia improves the identifica- A comprehensive taxonomic system is presented in tion of patients with more complex pain problems. Table 4. The diagnostic criteria for the less common Consequently, frequency and duration of “jaw pain” is TMD were derived, in part, from the best available assessed by the DC/TMD Symptom Questionnaire— definitions for those disorders included in existing Long Form that was developed for the TMJ Impact AAOP guidelines. This was augmented by a review Project; this is available on the Consortium website.103 of the literature for diagnostic criteria defining oth- er disorders not identified in the AAOP guidelines. Changes to Original RDC/TMD TMJ Diagnoses The comprehensive taxonomic system and criteria A diagnostic category of DD with reduction with in- for these disorders is available43 and will be contin- termittent limited opening (ie, episodic self-limiting ually updated on the Consortium website as new in- “closed lock”) was included in the new DC/TMD. formation emerges. These AAOP-based diagnostic This is a common, clinically significant “mechanical” criteria were developed by clinicians and research- joint disorder that can require treatment. Another ers according to their experience and the literature.40 newly included diagnostic category is the mechani- Although these criteria have content validity, their cri- cal joint disorder of TMJ dislocation characterized by terion validity has not been assessed, so special cau- “open lock” of the jaw and typically diagnosed based tion should accompany their use clinically. Treatment on patient history. If the patient is able to reduce decisions based on these diagnoses should be this dislocation, it is termed “subluxation,” and if the under­taken with careful consideration of all risks and dislocation requires an interventional reduction, it is benefits associated with the resulting care plan. termed “luxation.” Sufficient data were only available to assess the diagnostic validity of subluxation.104 Journal of Oral & Facial Pain and Headache 19 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. Schiffman et al Nomenclature functional behaviors may operate at several levels, Since the terms osteoarthrosis and osteoarthritis including that of possibly repetitive trauma to the have not been consistently used in medicine, these masticatory system, and appear to be significant terms were subclassified under the broader term predictors for TMD onset and are strongly asso- DJD. Use of DJD is also endorsed by the American ciated with chronic TMD pain.116,117 In addition, the Association of Oral and Maxillofacial Surgeons.107 presence of significant psychosocial distress should When pain co-occurs with DJD, the additional di- be considered as a particularly important comorbid agnosis of arthralgia can be used—as is the case condition contributing to TMD onset as well as being with DD. A former diagnosis of osteoarthritis by the associated with chronic TMD pain.64,118 Widespread RDC/TMD is now dually coded as degenerative joint pain suggests potential systemic disorders, including disease and joint pain (ie, arthralgia). rheumatic diseases and/or central sensitization (eg, fibromyalgia), suggesting the need for further medi- Changes to Original RDC/TMD Axis II cal assessment. It is therefore advisable that the core IMMPACT guidelines for clinical trials assessing set of Axis II instruments be used routinely in all clin- pain recommend that patients be assessed for pain ical assessments. Use of the Axis II instruments in intensity and emotional functioning as well as gen- the clinical setting will permit assessment of the bio­ eral and disease-specific physical functioning.60 behavioral constructs currently known to be relevant These four domains are assessed using the core to pain disorders and thereby lead to appropriate in- Axis II instruments of GCPS (pain intensity subscale), terventions as guided by the patient’s status.18,21 PHQ-4 (emotional functioning), GCPS (general An in-depth evaluation of the patient’s psycho- physical functioning by using the pain interference social status is important for all research studies subscale), and JFLS (disease-specific physical func- comparing TMD treatment modalities. Axis II psycho- tioning). Domains that bridge behavior with Axis I and social factors have better prognostic value than Axis I are of direct utility for the clinician and researcher physical diagnoses.18,112 Research that does not take have been added. The biopsychosocial model of pain into account these important risk factors cannot im- recognizes that pain is not purely a sensory process prove our understanding of TMD and of which treat- but that it is always accompanied by cognitive, emo- ments work and why.24 tional, and behavioral aspects which influence how a patient reacts to and reports pain, and which, in Clinical Application of the New DC/TMD turn, result in coping strategies that may be helpful The comprehensive evaluation necessary to design or harmful in maintaining adequate functioning.22,23 If a specific patient’s care plan is beyond the scope these coping strategies are harmful, they