New Evidence-Based Diagnosis Criteria for TMD
The new criteria for the diagnosis of temporomandibular joint disorders (TMDs) comprise an improved screening tool to help researchers and health professionals more readily differentiate the most common forms of TMD and reach accurate diagnoses that are grounded in supportive scientific evidence, according to the National Institute of Dental and Craniofacial Research (NIDCR), a part of the National Institutes of Health, which supported part of the research.
“We’ve had diagnostic criteria for years,” said Eric Schiffman, DDS, a coauthor of the new guidelines, who studies TMD at the University of Minnesota School of Dentistry in Minneapolis. “What is unique here is instead of a panel of experts empirically deciding best practices, we relied on science as a methodology to test our best assumptions and see if we were actually correct.”
Called DC/TMD, the latest criteria are an extension of earlier research that suggests that TMD was more than just jaw pain. In 1992, the Research Diagnostic Criteria for TMD (RDC/TMD) reflected this awareness. According to NIDCR, they were the first to integrate biological, psychological, and social factors into two distinct protocols, or axes. Axis I was designed to evaluate the physical diagnoses, while Axis II characterized the nature of a person’s pain, distress, and disability. The criteria were translated into 18 languages and became the most widely used diagnostic system among TMD researchers.2
But the RDC/TMD dual axes represented a first step with biopsychosocial diagnostic criteria. In the early 2000s, the NIDCR assembled a group of experts to lead the first comprehensive assessment of the criteria. The group found Axis I in particular to be less valid than previously thought, leading to a mandate from the TMD clinical and research communities to create the diagnostic equivalent of RDC/TMD 2.0.3
All agreed at the outset that the “R” was no longer needed. Research criteria, while useful for scientists in the laboratory and clinic, can leave researchers and health care providers using different diagnostic terms, measures, and tools.
“A common language allows clinicians to communicate more easily to researchers about their daily diagnostic challenges,” said Richard Ohrbach, DDS, PhD, a co-author of the publication who studies TMD at the University at Buffalo School of Dental Medicine, in New York. “Conversely, a common language allows research findings to be more easily integrated into a clinical setting and improve patient care.”
The DC/TMD start with a refined version of Axis I, the physical assessment. It begins with an easily administered patient questionnaire that is specially designed to detect pain-related TMD. If TMD is detected, the protocol moves on to newly crafted diagnostic criteria to help practitioners differentiate among the common subtypes. In field tests, the diagnostic criteria for painful TMD were found to have at least 86% sensitivity and 97% specificity.
Axis II, the psychosocial assessment, screens patients to assess pain location, pain intensity, pain-related disability, psychological distress, degree of jaw dysfunction, and the presence of oral habits (grinding teeth) that may contribute to the dysfunction. If more information is needed, a more comprehensive follow-up questionnaire is available to tap into additional anxiety measures and the possible presence of other pain-causing physical ailments. Both instruments have been scientifically validated.
“By diagnosing the person, beyond only the physical condition, a whole avenue of treatment options opens up,” said Dr. Schiffman. “Instead of prescribing mouth guards, exercises, or surgery, practitioners can consider trying biobehavioral treatments, including relaxation techniques and biofeedback, to help the patient successfully manage their TMD. In short, you can better customize the treatment to fit the whole person, not just their disorder.”