The Research Diagnostic Criteria for Temporomandibular Disorders. VI: Future Directions

The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Validation Project has provided the first comprehensive assessment of reliability and validity of the original Axis I and II. In addition, Axis I of the RDC/TMD was revised with estimates of reliability and validity. These findings are reported in the five preceding articles in this series. The aim of this article is to present further revisions of Axis I and II for consideration by the TMD research and clinical communities. Potential Axis I revisions include addressing concerns with orofacial pain differential diagnosis and changes in nomenclature in an attempt to provide improved consistency with other musculoskeletal diagnostic systems. In addition, expansion of the RDC/TMD to include the less common TMD conditions and disorders would make it more comprehensive and clinically useful. The original standards for diagnostic sensitivity (≤0.70) and specificity (≤0.95) should be reconsidered to reflect changes in the field since the RDC/TMD was published in 1992. Pertaining to Axis II, current recommendations for all chronic pain conditions include standardized instruments and expansion of the domains assessed. In addition, there is need for improved clinical efficiency of Axis II instruments and for exploring methods to better integrate Axis I and II in clinical settings.

clinical utility;diagnostic criteria;nomenclature;research;temporomandibular disorders

1. Laskin D, Greenfield W, Gale E, et al (eds). The President’s Conference on the Examination, Diagnosis and Management of Temporomandibular Disorders. Chicago: American Dental Association, 1983.

2. Sessle BJ, Bryant PS, Dionne RA (eds). Temporomandibular Disorders and Related Pain Conditions. Seattle: IASP, 1995.

3. Fricton JR, Dubner R (eds). Advances in Pain Research and Therapy: Orofacial Pain and Temporomandibular Disorders. New York: Raven, 1995.

4. Management of temporomandibular disorders. National Institutes of Health technology assessment conference statement. J Am Dent Assoc 1996;127:1595–1606.

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

6. DeRouen T. Statistical and methodological issues in temporomandibular disorder research. In: Sessle BJ, Bryant PS, Dionne RA (eds). Temporomandibular Disorders and Related Pain Conditions. Seattle: IASP, 1995:459–465.

7. 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.

8. Look JO, John MT, 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.

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

10. Ohrbach R, Turner JA, Sherman JJ, et al. The research diagnostic criteria for temporomandibular disorders. IV: Evaluation of psychometric properties of the axis II measure. J Orofac Pain 2010;24:48–62.

11. Schiffman EL, Ohrbach R, Truelove E, et al. The research diagnostic criteria for temporomandibular disorders. V: Methods used to establish and validate revised axis I diagnostic algorithms. J Orofac Pain 2010;24:63–78.

12. 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.

13. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, ed 2. Cephalalgia 2004;24(suppl 1):9–160.

14. Goulet JP, 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, 2008:135–143.

15. Türp JC, Kowalski CJ, Stohler CS. Pain descriptors characteristic of persistent facial pain. J Orofac Pain 1997;11:285–290.

16. Türp JC, Kowalski CJ, Stohler CS. Generic pain intensity scores are affected by painful comorbidity. J Orofac Pain 2000;14:47–51.

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

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

19. Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical review of manual palpation for identifying myofascial trigger points: Evidence and clinical significance. Arch Phys Med Rehabil 2008;89:1169–1176.

20. Tough EA, White AR, Richards S, Campbell J. Variability of criteria used to diagnose myofascial trigger point pain syndrome: Evidence from a review of the literature. Clin J Pain 2007;23:278–286.

21. Gonzalez YM, Mohl ND. Masticatory muscle pain and dysfunction. In: Laskin DM, Greene CS, Hylander WL (eds). TMDs: An Evidence-Based Approach to Diagnosis and Treatment. Chicago: Quintessence, 2006:255–269.

22. Kircos LT, Ortendahl DA, Mark AS, Arakawa M. Magnetic resonance imaging of the TMJ disc in asymptomatic volunteers. J Oral Maxillofac Surg 1987;45: 852–854.

23. Katzberg RW, Westesson PL, Tallents RH, Drake CM. Anatomic disorders of the temporomandibular joint disc in asymptomatic subjects. J Oral Maxillofac Surg 1996; 54:147–153.

24. Tasaki MM, Westesson PL, Isberg AM, Ren Y-F, Tallents RH. Classification and prevalence of temporomandibular joint disk displacement in patients and symptom-free volunteers. Am J Orthod Dentofac Orthop 1996;109: 249–262.

25. Larheim TA, Westesson PL, Sano T. Temporomandibular joint disk displacement: Comparison in asymptomatic volunteers and patients. Radiology 2001;218:428–432.

26. Adams JC, Hamblen DL. Outline of Orthopedics, ed 11. Edinburgh: Churchill Livingstone, 1990.

27. American Association of Oral and Maxillofacial Surgeons. Parameters and Pathways: Clinical Practice Guidelines for Oral and Maxillofacial Surgery. J Oral Maxillofac Surg 2001;(suppl).

28. Stegenga B, de Bont LG, Boering G. Classification of temporomandibular joint osteoarthrosis and internal derangement. Part II: Specific diagnostic criteria. Cranio 1992; 10:107–117.

29. Arthritis Foundation. Primer on Rheumatic Diseases, ed 12. Atlanta: Arthritis Foundation, 2001.

30. Altman RD. Criteria for classification of clinical osteoarthritis. J Rheumatol Suppl 1991;18:10–12.

31. Haskin CL, Milam SB, Cameron IL. Pathogenesis of degenerative joint disease in the human temporomandibular joint. Crit Rev Oral Biol Med 1995;6:248–277.

32. Brosseau L, Yonge KA, Robinson V, et al. Thermotherapy for treatment of osteoarthritis. Cochrane Database Syst Rev 2003;(4):CD004522.

33. Clark GT, Delcanho RE, Goulet JP. The utility and validity of current diagnostic procedures for defining temporomandibular disorder patients. Adv Dent Res 1993;7: 97–112.

34. Widmer CG. Review of the literature: Reliability and validation of examination methods. In: Dworkin SF, LeResche L (eds). Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord Facial Oral Pain 1992;6:318–326.

35. Al-Ani MZ, Davies SJ, Gray RJM, Sloan P, Glenny AM. Stabilisation splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database Syst Rev 2004;(1): CD002778.

36. Truelove E, Huggins KH, Mancl L, Dworkin SF. The efficacy of traditional, low-cost and nonsplint therapies for temporomandibular disorder: A randomized clinical trial. J Am Dent Assoc 2006;137:1099–1107.

37. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice, ed 2. Upper Saddle River, NJ: Prentice Hall Health, 2000:107–108.

38. Turk DC, Dworkin RH, Allen RR, et al. Core outcome domains for chronic pain clinical trials: IMMPACT recommendations. Pain 2003;106:337–345.

39. Dworkin RH, Turk DC, Farrar JT, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 2005;113:9–19.

40. Rose M, Bjorner JB, Becker J, Fries JF, Ware JE. Evaluation of a preliminary physical function item bank supported the expected advantages of the patient-reported outcomes measurement information system (PROMIS). J Clin Epi 2008;61:17–33.

41. Dura E, Andreu Y, Galdon MJ, et al. Psychological assessment of patients with temporomandibular disorders: Confirmatory analysis of the dimensional structure of the Brief Symptoms Inventory 18. J Psychosom Res 2006; 60:365–370.

42. De Leeuw R, Bertoli E, Schmidt JE, Carlson CR. Prevalence of traumatic stressors in patients with temporomandibular disorders. J Oral Maxillofac Surg 2005; 63:42–50.

43. Turner JA, Dworkin SF. Screening for psychosocial risk factors in patients with chronic orofacial pain: Recent advances. J Am Dent Assoc 2004;135:1119–1125.

44. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606–613.

45. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care 2003;41:1284–1292.

46. Melzack R. The short-form McGill pain questionnaire. Pain 1987;30:191–197.

47. Ohrbach R, Granger CV, List T, Dworkin SF. Pain-related functional limitation of the jaw: Preliminary development and validation of the jaw functional limitation scale. Comm Dent Oral Epidem 2008;36:228–236.

48. Ohrbach R, Larsson P, List T. The jaw functional limitation scale: Development, reliability and validity of 8-item and 20-item versions. J Orofac Pain (in press).

49. John MT, Hujoel P, Miglioretti DL, Leresche L, Koepsell TD. Dimensions of oral-health related quality of life. J Dent Res 2004;83:956–960.

50. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: Manual and Interpretation Guide. Boston: The Health Institute, New England Medical Center, 1993.

51. Ware JE, Kosinski M, Keller SD. SF-36 Physical and Mental Health Survey Summary Scales: A User’s Manual. Boston: The Health Institute, New England Medical Center, 1994.

52. Ware J, Kosinski M, Keller SD. A 12-item short-form health survey: Construction of scales and preliminary test of reliability and validity. Med Care 1996;34:220–233.

53. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatry Res 1989; 28:193–213.

54. McNair DM, Lorr M, Droppleman LF. Profiles of Mood States. San Diego: Educational and Industrial Testing Services, 1971.

55. Guy W. ECDEU Assessment Manual for Psychopharmacology. DHEW Publication No. ADM 76-338. Washington, DC: US Government Printing Office, 1976.

56. Macfarlane GJ. Looking back: Developments in our under-standing of the occurrence, aetiology and prognosis of chronic pain 1954–2004. Rheumatology 2005;44(suppl 4): iv23–iv26.

57. Diatchenko L, Nackley AG, Slade GD, Fillinigim RB, Maixner W. Topical review: Idiopathic pain disorders –Pathways of vulnerability. Pain 2006;123:226–230.

58. Dworkin SF. Illness behavior and dysfunction: Review of concepts and application to chronic pain. Can J Physiol Pharmacol 1991;69:662–671.

59. Dworkin SF, Turner JA, Mancl L, et al. A randomized clinical trial of a tailored comprehensive care treatment program for temporomandibular disorders. J Orofac Pain 2002;16:259–276.

60. Dworkin SF, Huggins KH, Wilson L, et al. A randomized clinical trial using research diagnostic criteria for temporomandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. J Orofac Pain 2002;16:48–63.

61. Gatchel RJ, Stowell AW, Wildenstein L, Riggs R, Ellis E. Efficacy of an early intervention for patients with acute temporomandibular disorder-related pain: A one-year outcome study. J Amer Dent Assoc 2006;137:339–347.

62. Rudy TE, Turk DC, Kubinski JA, Zaki HS. Differential treatment responses of TMD patients as a function of psychological characteristics. Pain 1995;61:103–112.

63. Garofalo JP, Gatchel RJ, Wesley AL Ellis EI. Predicting chronicity in acute temporomandibular joint disorders using the research diagnostic criteria. J Amer Dent Assoc 2007;129:438–447.

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

65. 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.

66. 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.

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

68. McNamara JA, Seligman DA, Okeson JP. The role of functional occlusal relationships in temporomandibular disorders: A review. J Orofac Pain 1995;9:73–90.

69. Stohler CS. Craniofacial pain and motor function: Pathogenesis, clinical correlates and implications. Crit Rev Oral Biol Med 1999;10:504–518.

70. Sessle BJ, Bryant PS, Dionne RA. Preface. In: Sessle BJ, Bryant PS, Dionne RA (eds). Temporomandibular Disorders and Related Pain Conditions. Seattle: IASP Press, 1995:xiii–xiv.

71. Laskin DM. Temporomandibular disorders: A term past its time [editorial]? J Amer Dent Assoc 2008;139: 124–128.

72. National Institute of Dental and Craniofacial Research website. http://www.nidcr.nih.gov/HealthInformation/DiseasesAndConditions/default.htm. Accessed Feb 20, 2008.