The Research Diagnostic Criteria for Temporomandibular Disorders. V: Methods Used to Establish and Validate Revised Axis I Diagnostic Algorithms

Aims: To derive reliable and valid revised Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms for clinical TMD diagnoses. Methods: The multisite RDC/TMD Validation Project’s dataset (614 TMD community and clinic cases, and 91 controls) was used to derive revised algorithms for Axis I TMD diagnoses. Validity of diagnostic algorithms was assessed relative to reference standards, the latter based on consensus diagnoses rendered by two TMD experts using criterion examination data, including temporomandibular joint imaging. Cutoff points for target validity were sensitivity k≥ 0.70 and specificity k≥ 0.95. Reliability of revised algorithms was assessed in 27 study participants. Results: Revised algorithm sensitivity and specificity exceeded the target levels for myofascial pain (0.82, 0.99, respectively) and myofascial pain with limited opening (0.93, 0.97). Combining diagnoses for any myofascial pain showed sensitivity of 0.91 and specificity of 1.00. For joint pain, target sensitivity and specificity were observed (0.92, 0.96) when arthralgia and osteoarthritis were combined as “any joint pain.” Disc displacement without reduction with limited opening demonstrated target sensitivity and specificity (0.80, 0.97). For the other disc displacement diagnoses, osteoarthritis and osteoarthrosis, sensitivity was below target (0.35 to 0.53), and specificity ranged from 0.80 to meeting target. Kappa for revised algorithm diagnostic reliability was k≥ 0.63. Conclusion: Revised RDC/TMD Axis I TMD diagnostic algorithms are recommended for myofascial pain and joint pain as reliable and valid. However, revised clinical criteria alone, without recourse to imaging, are inadequate for valid diagnosis of two of the three disc displacements as well as osteoarthritis and osteoarthrosis.

reference standard;reliability;research diagnostic criteria;temporomandibular disorders;temporomandibular muscle and joint disorders;validity

1. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: Review criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:301–355.

2. Truelove EL, Pan W, Look JO, et al. The research diagnostic criteria for temporomandibular disorders. III. Validity of axis I diagnoses. J Orofac Pain 2010;24:35–47.

3. Schiffman EL, Truelove E, Ohrbach R, et al. The research diagnostic criteria for temporomandibular disorders. I. Overview and methodology for assessment of validity. J Orofac Pain 2010;24:7–24.

4. Ahmad M, Hollender L, Anderson Q, et al. Research diagnostic criteria for temporomandibular disorders (RDC/TMD): Development of image analysis criteria and examiner reliability for image analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:844–860.

5. University of Michigan Comprehensive Cancer Center web-site http://roadrunner.cancer.med.umich.edu/comp/docs/R. rpart.pdf. Accessed Feb 20, 2008.

6. Breiman L, Freidman JH, Olshen RA, Stone CJ. Classification and Regression Trees. Monterey, CA: Wadsworth, 1984.

7. Hastie T, Tibshirani R, Friedman JH. The Elements of Statistical Learning: Data Mining, Inference and Prediction. New York: Springer-Verlag, 2001.

8. Okeson JP (ed). Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. Chicago: Quintessence, 1996.

9. Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Arthritis Rheum 1986;29:1039–1049.

10. Steenks MH, de Wijer A, Lobbezoo-Scholte AM, Bosman F. Orthopedic diagnostic tests for temporomandibular and cervical spine disorders. In: Fricton J, Dubner R (eds). Orofacial Pain and Temporomandibular Disorders, vol21. New York: Raven, 1995.

11. Lobbezoo-Scholte AM, Steenks MH, Faber JA, Bosman F. Diagnostic value of orthopedic tests in patients with temporomandibular disorders. J Dent Res 1993;72: 1443–1453.

12. Lobbezoo-Scholte AM, de Wijer A, Steenks MH, Bosman F. Interexaminer reliability of six orthopaedic tests in diagnostic subgroups of craniomandibular disorders. J Oral Rehabil 1994;21:273–285.

13. Visscher CM, Lobbezoo F, Naeije M. A reliability study of dynamic and static pain tests in temporomandibular disorder patients. J Orofac Pain 2007;21:39–45.

14. Okeson JP. History and examination for temporomandibular disorders. In: Okeson JP. Management of Temporo mandibular Disorders and Occlusion. St. Louis: Mosby, 2008.

15. Ohrbach R, Gale EN. Pressure pain thresholds, clinical assessment, and differential diagnosis: Reliability and validity in patients with myogenic pain. Pain 1989; 39:157–169.

16. Howard J. Clinical diagnosis of temporomandibular joint derangements. In: Moffett BC (ed). Diagnosis of Internal Derangements of the Temporomandibular Joint. Seattle: University of Washington, 1984.

17. Wright EF. Manual of Temporomandibular Disorders. Ames, Iowa: Blackwell Munksgaard, 2005.

18. Look J, John M, Tai F, et al. The research diagnostic criteria for temporomandibular disorders. II. Reliability of axis I diagnoses and selected clinical measures. J Orofac Pain 2010;24:25–34.

19. Williamson JM, Lipsitz SR, Manatunga AK. Modeling kappa for measuring dependent categorical agreement data. Biostatistics 2000;1:191–202.

20. Orsini MG, Kuboki T, Terada S, Matsuka Y, Yatani H, Yamashita A. Clinical predictability of temporomandibular joint disc displacement. J Dent Res 1999;78:650–660.

21. Schiffman E, Anderson G, Fricton J, Burton K, Schellhas K. Diagnostic criteria for intraarticular TM disorders. Com munity Dent Oral Epidemiol 1989;17:252–257.

22. Limchaichana N, Nilsson H, Ekberg EC, Nilner M, Petersson A. Clinical diagnoses and MRI findings in patients with TMD pain. J Oral Rehabil 2007;34:237–245.

23. Eriksson L, Westesson PL, Rohlin M. Temporomandibular joint sounds in patients with disc displacements. Int J Oral Surg 1985;14:428–436.

24. Rohlin M, Westesson PI, Eriksson L. The correlation of temporomandibular joint sounds with joint morphology in fifty-five autopsy specimens. J Oral Maxillofac Surg 1985;43:194–200.

25. Manfredini D, Guarda-Nardini L. Agreement between research diagnostic criteria for temporomandibular disorders and magnetic resonance diagnoses of temporomandibular disc displacement in a patient population. Int J Oral Maxillofac Surg 2008;37:612–616.

26. Huddleston-Slater JJ, Van Selms MK, Lobbezoo F, Naeije M. The clinical assessment of TMJ sounds by means of auscultation, palpation or both. J Oral Rehabil 2002;29: 873–878.

27. Manfredini D, Basso D, Salmaso L, Guarda-Nardini L. Temporomandibular joint click sound and magnetic resonance-depicted disk position: Which relationship? J Dent 2008;36:256–260.

28. Marguelles-Bonnet RE, Carpentier P, Yung JP, Defrennes D, Pharaboz C. Clinical diagnosis compared with findings of magnetic resonance imaging in 242 patients with inter-nal derangement of the TMJ. J Orofac Pain 1995;9: 244–253.

29. Schmitter M, Kress B, Rammelsberg P. Temporomandibular joint pathosis in patients with myofascial pain: A comparative analysis of magnetic resonance imaging and a clinical examination based on a specific set of criteria. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:318–324.

30. Anderson GC, Schiffman EL, Schellhas KP, Fricton JR. Clinical vs. arthrographic diagnosis of TMJ internal derangement. J Dent Res 1989;68:826–829.

31. Ohlmann B, Rammelsberg P, Henschel V, Kress B, Gabbert O, Schmitter M. Prediction of TMJ arthralgia according to clinical diagnosis and MRI findings. Int J Prosthodont 2006;19:333–338.

32. Westesson PL, Katzberg RW, Tallents RH, Sanchez-Woodworth RE, Svensson SA. CT and MR of the temporomandibular joint: Comparison with autopsy speci-mens. Am J Roentgenol 1987;148:1165–1171.

33. Barclay P, Hollender LG, Maravilla KR, Truelove EL. Comparison of clinical and magnetic resonance imaging diagnosis in patients with disk displacement in the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:37–43.

34. Emshoff R, Rudisch A. Validity of clinical diagnostic criteria for temporomandibular disorders: Clinical versus magnetic resonance imaging diagnosis of temporomandibular joint internal derangement and osteoarthrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:50–55.

35. Yatani H, Sonoyama W, Kuboki T, Matsuka Y, Orsini MG, Yamashita A. The validity of clinical examination for diagnosing anterior disk displacement with reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85:647–653.

36. Yatani H, Suzuki K, Kuboki T, Matsuka Y, Maekawa K, Yamashita A. The validity of clinical examination for diagnosing anterior disk displacement without reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85:654–660.

37. Tognini F, Manfredini D, Montagnani G, Bosco M. Is clinical assessment valid for the diagnosis of temporomandibular joint disk displacement? Minerva Stomatol 2004;53:439–448.

38. Schmitter M, Kress B, Leckel M, Henschel V, Ohlmann B, Rammelsberg P. Validity of temporomandibular disorder examination procedures for assessment of temporomandibular joint status. Am J Ortho Dentofac Orthopedics 2008;133:796–803.

39. Sessle BJ. Acute and chronic craniofacial pain: Brainstem mechanisms of nociceptive transmission and neuroplasticity, and their clinical correlates. Crit Rev Oral Biol Med 2000;11:57–91.

40. Johnson DB, Templeton MC. The feasibility of palpating the lateral pterygoid muscle. J Prosthet Dent 1980; 40:318–323.

41. Turp JC, Minagi S. Palpation of the lateral pterygoid region in TMD: Where is the evidence? J Dent 2001; 29:475–483.

42. Sato H, Matusgama T, Ishikawa M, Ukon S, Zeze R, Kodama J. A study of the accuracy of posterior digastric muscle palpation [abstract]. J Orofac Pain 2000;14:239.

43. Stratmann U, Mokrys K, Meyer U, et al. Clinical anatomy and palpability of the inferior lateral pterygoid muscle. J Prosthet Dent 2000;83:548–554.

44. Turp JC, Arima T, Minagi S. Is the posterior belly of the digastric muscle palpable? A qualitative systematic review of the literature. Clin Anat 2005;18:318–322.

45. Shaefer JR, Jackson DL, Schiffman EL, Anderson QN. Pressure-pain thresholds and MRI effusions in TMJ arthralgia. J Dent Res 2001;80:1935–1939.

46. Steenks MH, deWijer A. Validity of the research diagnostic criteria for temporomandibular disorders axis I in clinical and research settings. J Orofac Pain 2009;23:9–16.

47. Greene CS. Critical commentary on the focus article. Validity of the research diagnostic criteria for temporomandibular disorders axis I in clinical and research set-tings. J Orofac Pain 2009;23:20 –23.

48. Schwarzer AC, Derby R, Aprill CN, Fortin J, Kine G, Bogduk N. The value of the provocation response in lumbar zygapophyseal joint injections. Clin J Pain 1994; 10:309–313.

49. McFadden JW. The stress lumbar discogram. Spine 1988;13:931–933.

50. Thevenet P, Gosselin A, Bourdonnec C, et al. pHmetry and manometry of the esophagus in patients with pain of the angina type and a normal angiography. Gastroenterol Clin Biol 1988;12:111–117.

51. Janssens J, Vantrappen G, Ghillebert G. 24-hour record-ing of esophageal pressure and pH in patients with non-cardiac chest pain. Gastroenterology 1986;90:1978–1984.

52. Vaksmann G, Ducloux G, Caron C, Manouvrier J, Millaire A. The ergometrine test: Effects on esophageal motility in patients with chest pain and normal coronary arteries. Can J Cardiol 1987;3:168–172.

53. Couppe C, Torelli P, Fuglsang-Frederiksen A, Anderson KV, Jensen R. Myofascial trigger points are very prevalent in patients with chronic tension-type headache: A double-blinded controlled study. Clin J Pain 2007;23:23–27.

54. Wise CM, Semble EL, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: A study of 100 patients. 1992;73:147–149.

55. Kokkonen SM, Kurunlahti M, Tervonen O, Ilkko E, Vanharanta H. Endplate degeneration observed on magnetic resonance imaging of the lumbar spine: Correlation with pain provocation and disc changes observed on computed tomography diskography. Spine 2002;27:2274–2278.

56. Goulet, J, Palla S. The path to diagnosis. In: Sessle BJ, Lavigne GJ, Lund JP, Dubner R (eds). Orofacial Pain: From Basic Science to Clinical Management. Chicago: Quintessence, 2008.

57. de Leeuw R (ed). Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. Chicago: Quintessence, 2008.

58. Bossuyt PM, Reitsma JB, Bruns DE, et al. The STARD statement for reporting studies of diagnostic accuracy: Explanation and elaboration. Ann Intern Med 2003;138: W1–W12.

59. International Consortium for RDC-TMD-based Research website. http://www.rdc-tmdinternational.org. Accessed Nov 12, 2009.