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Network Symposium to be presented at IADR, Barcelona, Spain, July 2010 Session Title: Diagnostic Criteria for TMD (DC/TMD): A new version of the RDC/TMD Group(s): International RDC/TMD Consortium Network/Neuroscience

Session Type: Symposium—Group/Division Sponsored

Description: The RDC/TMD has been a successful approach for classifying the most common types of TMD. The classification system was introduced in 1992; since then, it has been translated into 20 languages and cited in an overwhelming number of publications. Recently, the NIDCR funded a large, multi-site study to examine the reliability and validity of the RDC/TMD and, as appropriate, to recommend revisions to that protocol. These revisions were further developed into the Diagnostic Criteria for TMD (DC/TMD)—a new version of the RDC/TMD—in an International Consensus Workshop at the 2009 IADR meeting. This symposium should be accessible to experienced investigators, academic clinicians, and basic scientists interested in opportunities for TMD research.

Program: The symposium will present comments and recommendations from the DC/TMD workshop. All symposium speakers were involved in the development of these criteria. Thomas List and Mark Drangsholt (moderators) will begin with a short introduction to the new criteria and an orientation in its use in clinical praxis and in research settings. Three topics will then be presented:

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

Diagnostic algorithms for TMJ disorders. Eric Schiffman (University of Minneapolis, Minnesota, US—principal investigator of the NIDCR/NIH-funded project “Research Diagnostic Criteria: Reliability and Validity”.

Assessment of the behavioral domain in TMD. Richard Ohrbach (University at Buffalo, US)—psychologist, experienced clinician, and co-principal investigator of the NIDCR-sponsored validation project.

Educational Objectives:

1. Present instruments for screening and examining TMD patients in clinical praxis and research settings.

2. Discuss specifications for diagnosing muscle and TMJ disorders. 3. Present instruments for assessing the behavioral domain in pain.

Organizers and Moderators: Thomas List (Malmö University, Sweden) and Mark Drangsholt

(University of Washington, Seattle, WA, US)

Diagnostic Criteria for Temporomandibular Disorders (DC/TMD):

A Symposium held at the IADR/Barcelona, July 2010

• Thomas List, Malmö University

• Jean-Paul Goulet, Laval University

• Eric Schiffman, University of Minnesota

• Richard Ohrbach, University at Buffalo

• Mark Drangsholt, University of Washington

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

• From the RDC/TMD to the DC/TMDThomas List

• Diagnostic algorithms for myofascial pain and headache attributed to TMD. Jean-Paul Goulet

• Diagnostic algorithms for TMJ disorders.Eric Schiffman

• Assessment of the behavioral domain in TMDRichard Ohrbach

• SummaryMark Drangsholt

Program

From RDC/TMD to DC/TMDThomas List

• 1992 RDC/TMD published JOP.

• 2008, IADR Toronto Validation Studies of the RDC/TMD: Progress toward Version 2.

• 2009, IADR Miami International Consensus Workshop:Convergence on an Orofacial Pain Taxonomy.

• 2010/2011 DC/TMD submitt JADA.

RDC/TMD

Comprises:• A dual axis approach.

• Clearly operationalized data collection procedures.

• Strict diagnostic criteria.

RDC/TMD

• Has been used in a wide range of experimental, clinical, and population-based studies among adults and adolescents around the world.

• Is translated into 20 languages.

• Is one of the most commonly cited references in dental literature. A search in Web of Science generated 918 citations.

Critical review of RDC/TMD

• The diagnostic criteria for the physical diagnosis need to be refined.

• The range of disorders represented by the

RDC/TMD needs to be expanded.

• The assessment domains comprising Axis II need to be reviewed and potentially updated.

The NIDCR sponsored project – the RDC/TMD Validation Project

2001-2006

The Research Diagnostic Criteria for TMD • I: overview and methodology for assessment of

validity. • II: reliability of Axis I diagnoses and selected clinical

measures. • III: validity of Axis I diagnoses.• IV: evaluation of psychometric properties of the Axis

II measures. • V: methods used to establish and validate revised

Axis I diagnostic algorithms.• VI: future directions. • Research diagnostic criteria for temporomandibular

disorders (RDC/TMD): development of image analysis criteria and examiner reliability for image analysis.

IADR Toronto 2008Validation Studies of the RDC/TMD: Progress towards

Version 2

• Jean-Paul Goulet• John Look, Eric Schiffman,

Edmond Truelove, Mansur Ahmad, Richard Ohrbach.

• Frank Lobbezoo, SandroPalla. Bouwijn Stegenga, Mike John, Rigmor Jensen,Arne Petersson, Jennifer Haythornthwaite, Samuel Dworkin.

• Peter Svensson, Chuck Green

IADR Miami 2009International Consensus Workshop:

Convergence on an Orofacial Pain Taxonomy

Workshop goals• Finalize the revision of the RDC/TMD into a Diagnostic

Criteria for Temporomandibular Disorders (DC/TMD), which would be more appropriate for routine clinical implementation

• Provide a broad foundation for the further development of suitable diagnostic systems for not only TMD but also orofacial pain.

• Provide research recommendations to improve our understanding of TMD and orofacial pain

IADR MiamiInternational Consensus Workshop:

Convergence on an Orofacial Pain Taxonomy

Workshop participation: • International RDC/TMD Consortium Network

• SIG Orofacial Pain

• NIDCR

• American Academy of Orofacial Pain

• European Academy of Craniomandibular Disorders

• International Headache Society

• Other disciplines included: radiology, psychology, ontology, neurology and patient advocacy.

Description of the Workshop

• Presentations: Systematic review guidelines, biomedical ontology and patient advocacy.

• Workgroup made revisions of respective parts of the RDC/TMD

• Each workgroup presented the recommendations for critique by the others.

• Delphi-like voting for determingwhether sufficient concensus had been achieved.

IADR Symposium, Barcelona, 2010 IADR Symposium, Barcelona, 2010

Outline

1. RDC/TMD (1992) requirements for the diagnosisof « Group I ‐Muscles disorders »

2. DC/TMD for « Group I ‐Muscles disorders »

3. Specifications for clinical assessment: ‐ RDC/TMD vs DC/TMD

4. Headache attributed to TMD

5. Future aspects

JPG/FMDJPG/FMD‐‐ULUL


Ongoing pain in the face, jaw, temple, in the past month?

Total number of tender muscle sites out of 20

Ongoing pain on same side as palpation pain

Pain free opening(with vertical incisal overlap)

Passive stretch (MAO – UOWoP)

MYOFASCIAL PAIN MYOFASCIAL PAIN WITH

LIMITED OPENING

NO GROUP I DIAGNOSIS

NO

NO

YES

YES

3 or >

< 40 mm

40 mm or >< 5 mm

5 mm or >

< 3

RDC/TMD (1992) ALGORITHM


GROUP‐I: MUSCLE DISORDERS

RDC/TMD RDC/TMD (1992)(1992)

RDC/TMD RDC/TMD RevisedRevised **

DC/TMD DC/TMD ****

Ia: Myofascial pain withno limited opening

Ib: Myofascial pain withlimited opening

Ia: Myofascial pain withno limited opening

Ib: Myofascial pain with limited opening

Ia: Myofascial pain

Ib: Myofascial pain with referral


* Schiffman et al. J Orofacial Pain, 2010

** Miami Consensus Workshop, 2009

Ongoing pain in the face, jaw, temple, in the past month AND pain modification with movement, function and parafunction

PLUSExaminer confirmation of pain location in a masticatory structure

PLUS

At least « 1 »masseter or temporalis muscle site painful to palpationOR

Pain in masseter or temporalis with maximum unassisted or assisted openingPLUS

« FAMILIAR PAIN »

MYOFASCIAL PAIN WITH REFERRAL

NO MYOFASCIAL PAIN DIAGNOSIS

DC/TMD ALGORITHM FOR MYOFASCIAL PAIN

YES


NO

« REFERRED PAIN »on palpation of the masseter or temporalis

YESNO

MYOFASCIAL PAIN

MYOFASCIAL PAIN ASSESSMENT

CLINICAL HISTORYCLINICAL HISTORY RDC1992

RDCRevised

DC

Ongoing pain in the face, jaw, temple in the past month?

Examiner confirmation of pain location

Pain modification with movement, function and parafunction


MYOFASCIAL PAIN ASSESSMENT

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION RDC1992

RDCRevised

DC

Patient’s report of pain location

Muscle pain upon palpation

Patient’s report of masseter or temporalis pain with mandibular opening

Patient’s report of « familiar pain »

Patient’s report of « referred pain »

Measurement of the vertical range of motion of the mandible


MYOFASCIAL PAIN ALGORITHMSSENSITIVITY / SPECIFICITYSENSITIVITY / SPECIFICITY

RDC/TMD1992

RDC/TMDRevised *

DC/TMD

Myofascial pain withno limitation

0,75 / 0,97 0,82 / 0,99 n/a

Myofascial pain with limitation

0,83 / 0,99 0,93 / 0,97 n/a

Myofascial pain n/a n/a 0,84 / 0,95

Myofascial pain withreferral

n/a n/a 0,85 / 0,98

Any myofascial pain 0,82 / 0,98 0,91 / 1,00 0,90 / 1,00

JPG/FMDJPG/FMD‐‐ULUL* Schiffman et al. J Orofacial Pain, 2010

MUSCLE PALPATION SITES

RDC/TMD (1992)RDC/TMD (1992) DC/TMDDC/TMD

ExtraoralExtraoral muscle sites muscle sites (16)(16)

‐‐ TemporalisTemporalis anterioranterior‐‐ TemporalisTemporalis middlemiddle‐‐ TemporalisTemporalis posteriorposterior‐‐MasseterMasseter originorigin‐‐MasseterMasseter bodybody‐‐MasseterMasseter insertioninsertion‐‐ PosteriorPosterior mandibular mandibular regionregion‐‐ SubmandibularSubmandibular regionregion

ExtraoralExtraoral muscle sitesmuscle sites (12)(12)

‐‐ TemporalisTemporalis anterioranterior‐‐ TemporalisTemporalis middlemiddle‐‐ TemporalisTemporalis posteriorposterior‐‐MasseterMasseter originorigin‐‐MasseterMasseter bodybody‐‐MasseterMasseter insertioninsertion

IntraoralIntraoral muscle sitesmuscle sites (4)(4)

‐‐ LateralLateral pterygoidpterygoid areaarea‐‐ Tendon of Tendon of temporalistemporalis

IntraoralIntraoral muscle sitesmuscle sites (0)(0)


SPECIFICATIONS FOR MUSCLE PALPATION

RDC/TMD (1992)RDC/TMD (1992) DC/TMDDC/TMD

2 2 lbslbs of pressure for of pressure for temporalistemporalis and and massetermassetermuscle sitesmuscle sites

Minimum of 2 Minimum of 2 lbslbs of pressure of pressure (range 2(range 2‐‐3 3 lbslbs) for ) for temporalistemporalisand and massetermasseter muscle sitesmuscle sites

1 lb of pressure for 1 lb of pressure for posteriorposteriormandibular and mandibular and submandibularsubmandibular regionsregions

n/an/a

1 lb of pressure for 1 lb of pressure for intraoralintraoralmuscle sitesmuscle sites n/an/a

n/an/a PresencePresence of of referredreferred painpain


HEADACHE,TMD,OROFACIAL PAIN

Gonçalvez et al. 2010

Studginski‐Barbosa et al. 2010

Bevilaqua Grossi et al. 2009

Ballegaard et al. 2008

Glaros et al. 2007

Mongini 2007

Storm and Wänman 2006

Mitrirattanakul and Merril2006

Ciancaglini and Radaelli2001

Watts et al. 1986


SECONDARY HEADACHES (ICHD‐II 2004)

11.1 Headache attributed to disorder of cranial bone11.2 Headache attributed to disorder of neck11.3 Headache attributed to disorder of eyes11.4 Headache attributed to disorder of ears11.5 Headache attributed to rhinosinusitis11.6 Headache attributed to disorder of teeth,

jaws or related structures11.7 Headache attributed to TMJ disorder11.8 Headache attributed to other disorder of

cranium, neck, eyes, nose, sinuses, teeth, mouth or other facial or cervical structures


11.7 HEADACHE OR FACIAL PAIN ATTRIBUTED TO TMJ DISORDER (ICHD‐II 2004)

A. Recurrent pain in one or more regions of the headand/or face fulfilling criteria C and D

B. X‐ray, MRI and/or bone scintigraphy demonstrate TMJ disorder

C. Evidence that pain can be attributed to the TMJ disorder based on at least one of the following: 1. pain is precipitated by jawmovements and/or

chewing of hard or tough food2. reduced range of or irregular jaw opening3. noise from one or both TMJs during jawmovements4. tenderness of the join capsule(s) of one or both TMJs

D. Headache resolves within 3 months, and does not recur, after successful tratment of the TMJ disorder


SECONDARY HEADACHES (REVISED ICHD‐II 2009)

A. Headache of any type fulfilling criteria C and D

B. Another disorder scientifically documented to be able to cause headache has been diagnosed

C. Evidence of causation shown by at least 2 of the following:1. Headache has occurred in temporal relation to the onset of the

presumed causative disorder2. Headache has occurred or has significantly worsened in temporal

relation to the worsening of the the presumed causative disorder3. Headache has improved in temporal relation with the improvement

of the the presumed causative disorder

4. Headache has characteristics typical of the causative disorder

5. Other evidence exists of causation

D. The headache is not better accounted for by anotherheadache diagnosis


HEADACHE ATTRIBUTED TO TMD [SENSITIVITY 0,83; SPECIFICITY 0,86]*

A. Mild to moderate headache of any type, fulfilling criteria C and D

B. Pain‐related TMD demonstrated by clinically‐based diagnostic criteria

C. Evidence of causation shown by at least 2 of the following: 1. Headache has occurred in temporal relation to the onset of the pain‐related TMD2. Headache has occurred or has significantly worsened in temporal relation to

worsening of the pain‐related TMD3. Headache has improved in temporal relation to improvement of the pain‐related TMD 4. Headache can be attributed to pain‐related TMD based on the following:

a. History: Self reported headache in the temple(s) that is changed with jaw movement, function, oral habits, or rest

b. Examination: Report of familiar headache in the temple with palpation of the temporalis muscle(s)

5. Headache is located, at last in part, in the temple region of the head corresponding to the site of the temporalis muscle(s)

D. The headache is not better accounted for by another headache diagnosis

JPG/FMDJPG/FMD‐‐ULUL* Based on criteria A, C4, C5, D

OROFACIAL PAIN


…FUTURE ASPECTS Taxonomy that includes less commonmuscle disorders

Screening instruments for muscle disorders

Alternative methods for gathering data relevant to muscle disorders

Comprehensive clinical phenotype of muscle disorders

Differential subtype utility of muscle disorders in treatment decision making

Criteria for headache attributed to Axis‐I muscle disorders

DC/TMD and general practitioners


ACKNOWLEDGMENTSSponsors and funding agencies

• International RDC/TMD Consortium Network

• Orofacial Pain Special Interest Group of the IASP

• Canadian Institute for Health Research

• International Association for Dental research

• National Center for Biomedical Ontology

• Medotech

Miami Consensus Workshop Participants

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

• General members: Sharon Brooks, Werner Ceusters, Terri Cowley, Don Denucci, Mark Drangsholt, Sam Dworkin, Dominic Ettlin, Charly Gaul, Lou Goldberg, Jennifer Haythornthwaite, Lars Hollender, Mike John, John Kusiak, Antoon deLaat, Reny deLeeuw, Thomas List, Frank Lobbezoo, John Look, Marylee van derMeulen, Don Nixdorf, Richard Ohrbach, Sandro Palla, Arne Petersson, Paul Pionchon, Eric Schiffman, Barry Smith, Peter Svensson, Joanna Zakrzewska.



IADR Symposium, Barcelona, 2010 IADR Symposium, Barcelona, 2010

Overview1. TMD diagnostic algorithms:

Arthralgia, Disc Displacementsand Degenerative Joint Disease

* RDC/TMD (1992)

* Revised RDC/TMD (2010)

* New DC/TMD

2. Changes from RDC/TMD to DC/TMD

3. Future direction

Arthralgia, Arthritis, & Arthrosis

CLINICAL HISTORYCLINICAL HISTORY RDC/TMD(1992)

RevisedRDC/TMD

(2010)DC/TMD

ARTHRALGIA

In last month, ongoing pain in the face, jaw, temple, in front of the ear or in the ear

--

Pain modification with movement, function and parafunction

-- --

ARTHRITIS & ARTHROSIS

In last month, any noise present -- --

Arthralgia, Arthritis, & Arthrosis

PHYSICAL EXAMPHYSICAL EXAM RDC/TMD(1992)

RevisedRDC/TMD

(2010)DC/TMD

ARTHRALGIAPatient report of pain location -- --

Pain with joint palpation• Lateral pole• Posterior• Around lateral pole

--

--

--

Pain with ROM• including protrusive

--

--

Familiar pain with palpation and ROM --

ARTHRITIS and ARTHROSIS

Fine crepitus with palpationCoarse crepitus with palpatonCoarse crepitus is audible

----

--

--

Crepitus detected by subject with ROM --

Sensitivity and Specificity for Arthralgia, and Degenerative Joint Disease

Sensitivity Specificity

RDC/TMD

RevisedDC/TMD

RDC/TMD

RevisedDC/TMD

1. Arthralgia 0.38 N/A N/A 0.90 N/A N/A

2. Osteoarthritis 0.13 N/A N/A 1.00 N/AN/A

3. Osteoarthrosis 0.12 N/A N/A 0.99 N/A N/A

4. Joint Pain(1+2) 0.42 0.92 0.91 0.99 0.96 0.96

5. DegenerativeJoint Disease

(2+3)0.14 0.52 0.40 0.99 0.86 0.91

DC/TMD ARTHRALGIAI. History is positive for both of the following:

Ia. In last month, ongoing pain in the face, jaw, temple,

in front of the ear or in the ear

ANDIb. Pain modification with movement, function and parafunction

ANDII. Examination of the joint produces report of familiar pain by at

least 1 of the following provocation tests:IIa. Palpation of the lateral pole or around the lateral pole

ORIIb. Range of motion: Maximum unassisted or assisted

opening, right or left lateral movements, or protrusive movement

Sensitivity 0.91 / Specificity 0.96

DC/TMD Degenerative Joint Disease

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

ANDExamination is positive for at least one of the following:

IIa. Crepitus* detected with palpation during maximum unassisted opening, maximum assisted opening, lateral movements, or protrusive movements,

ORIIb. Report of crunching, grinding or grating noises

* Fine or coarse crepitus

Sensitivity 0.40/ Specificity 0.91

Disc DisplacementsRDC/TMD

(1992)

RevisedRDC/TMD

(2010)DC/TMD

CLINICAL HISTORYCLINICAL HISTORY

In last month, noise present --

Hx of significant limitation

PHYSICAL EXAMPHYSICAL EXAMClick detection 2 of 3 1 of 3 1 of 3

5 mm between reciprocal clicks -- --

Elimination of click -- --

Vertical opening (corrected)Unassisted: > 35 mm

Stretch: ≥ 5 mmStretch: ≥ 40 mm

Stretch: ≥ 40 mm

Lateral & protrusive movement ≥ 7 mm -- --

Uncorrected opening deviation -- --

Sensitivity and Specificity for Disc Displacements

Sensitivity SpecificityRDC/TMD Revised DC/TMD RDC/TMD Revised DC/TMD

Disc Displacementwith Reduction

0.42 0.46 0.33 0.92 0.90 0.94

Disc Displacementwith Reductionwith Intermittent Locking

N/A N/A 0.46 N/A N/A 0.97

Disc Displacementwithout Reductionwith Limited

0.26 0.80 0.80 1.00 0.97 0.97

Disc Displacementwithout Reductionwithout Limited

0.05 0.53 0.54 0.99 0.80 0.79

Any Disc Displacement

0.35 0.71 0.67 0.96 0.67 0.69

Disc Displacement with ReductionHistory is positive to the following:

I. In the last month, any noise present

ANDExamination:

IIa. Opening and closing click during at least 1 of 3 repetitions of jaw

opening and closing,

ORIIb. Either an opening or closing click during at least 1 of 3

repetitions of opening and closing,

andA click during at least 1 of 3 repetitions of each of the excursive movements (left lateral, right lateral, or protrusion)


DC/TMD Disc Displacement with Reduction with Intermittent Locking History is positive to both of the following:

Ia. In the last month, any noise present

ANDIb. In last month, report of intermittent locking

with limited opening

ANDExamination:

IIa. Same as disc displacement with reduction


DC/TMD Disc Displacement without Reduction with Limited Opening

History is positive for both of the following:Ia. Jaw lock or catch so that it would not open all the way

ANDIb. Limitation in jaw opening severe enough to interfere

with ability to eat.

ANDExamination is positive for the following:

II. Maximum assisted opening (passive stretch)

< 40mm including vertical incisal overlap

Sensitivity 0. 80 / Specificity 0.97

DC/TMD Disc Displacement without Reduction without Limited Opening

History is positive for both of the following:I. Same as disc displacement without reduction with

limited openingAND

Examination is positive for the following:II. Maximum assisted opening (passive stretch)

> 40mm including vertical incisal overlap


SUMMARY: DC/TMD

1. Valid diagnostic criteria for TMD muscle and joint pain for use in the clinical and research settings.

2. TMD pain is is the most common reason patients seek care.

3. Diagnosis of TMJ intra-articular disordersa. DD without reduction with limited opening

is reliable and valid.b. MRI is needed to definitively diagnosis ALL

other types of disc displacementsc. CT is needed for DJD

Future Direction1. Determine the clinical utility of subdividing arthralgia

consistent with ICHD:

Infrequent episodic/ frequent episodic/ chronic arthralgia.

2. Determine the clinical significance of disc displacements and degenerative joint disease to patient-reported outcomes of pain, functional limitations and disability since imaging is needed to definitively diagnosis of these disorders.

3. Expand the taxonomic system to include less common joint disorders using the AAOP DC* for these disorders

4. DC/TMD for phenotyping individuals for research and for clinical use.

5. Develop RDC/TMDv2 for advancing our knowledge base to better diagnose TMD.

* Best current source of expert-based DC

Miami Consensus Workshop Participants

Planning Committee:

Jean-Paul Goulet, Thomas List, Richard Ohrbach and Peter Svensson.

General members: Gary Anderson, Sharon Brooks, Werner Ceusters, Terri Cowley, Don Denucci, Mark Drangsholt, Sam Dworkin, Dominic Ettlin, Charly Gaul, Lou Goldberg, Yoly Gonzalez, Jennifer Haythornthwaite, Lars Hollender, RigmorJensen, Mike John, John Kusiak, Antoon deLaat, Reny deLeeuw,, Frank Lobbezoo, John Look, Bill Maixner, Marylee van der Meulen, AmbraMichelotti, Greg Murray, Don Nixdorf, Sandro Palla, Arne Petersson, Paul Pincion, Eric Schiffman, Barry Smith, Corine Visscher and Joanna Zakrzewska.

Sponsors and funding agenciesInternational RDC/TMD Consortium Network

Orofacial Pain Special Interest Group of the IASP

Canadian Institute for Health Research

International Association for Dental research

National Center for Biomedical Ontology

Medotech

Assessment of the behavioral domain in TMDEvolution of Axis II: RDC/TMD (1992) to the DC/TMD

Richard Ohrbach, DDS PhDUniversity at BuffaloSchool of Dental MedicineDepartment of Oral Diagnostic Sciences

IADR Symposium, Barcelona 2010Diagnostic Criteria for TMD (DC/TMD): A new version of the RDC/TMD

• Biobehavioral axis: assess, as a screener, characteristics of the person that describe the impact of pain, affect pain perception, and contribute to prognosis

• Presentation Overview– RDC/TMD Axis II – Validation Project – Consensus Workshop Recommendations– Problems with RDC/TMD Axis II– Integrated Assessment Model– Tailored Assessment– Summary

Why Axis II ?

RDC/TMD Axis II: Constructs

Assess wide range of potential functions affected by jaw problems

Jaw Disability Checklist

(ad hoc)

Representative index of pain severity that integrates time and fluctuations

Characteristic pain intensity

(Graded Chronic Pain Scale)

Hierarchical disability classification of life interference due to pain

Graded Chronic Pain

(Graded Chronic Pain Scale)

Assess physical symptoms [associated with functional somatic syndromes]

Non‐specific physical symptoms

(SCL‐90)

Assess core symptoms affecting pain modulation and coping, and indicative of morbidity

Depression

(adapted from SCL‐90)

Axis II Psychometric Properties - 1

0.87N/AChronic Pain Grade

0.890.95Pain Interference

0.910.84Characteristic Pain Intensity

0.720.84Non‐specific Physical Symptoms

0.780.91Depression

Lin’s CCCor Kappa

Cronbach’sAlpha

Measure

Internal Consistency and Temporal Stability of Axis II Measures

Ohrbach et al, Journal of Orofacial Pain, 2010

• Internal consistency is sufficient for all measures to be used for screening.

• Temporal stability ranges from 0.72 – 0.91, reflecting the dynamic character of the measured constructs.

Convergent and Discriminant Validity

Validity Measure

Axis II Measure

DepressionNonspecific Physical

Symptoms

GCP Pain Intensity

GCP Inter‐ference

Chronic Pain Grade

CES‐D 0.85 0.57 0.20 0.30 0.21

GHQ‐28 Somatic Sxs 0.38 0.46 0.23 0.29 0.19

MPI: Affect Distress 0.59 0.42 0.13 0.20 0.15

MPI: Pain Severity 0.29 0.46 0.65 0.47 0.37

MPI: Gen Activity ‐0.17 ‐0.13 ‐0.02 ‐0.09 ‐0.07

MPI: Interference 0.32 0.41 0.42 0.52 0.44

MPI: Dysfunctional 0.58 0.54 0.44 0.51 0.35

SF‐12v2: PCS 0.03 ‐0.28 ‐0.22 ‐0.33 ‐0.26

SF‐12v2: MCS ‐0.70 ‐0.42 ‐0.08 ‐0.20 ‐0.12




82456868Normal‐mod vs severe

36743186Normal vs mod‐severe

Non‐specific Physical Symptoms (SCL‐90)

98349156Normal‐mod vs severe

60685387Normal vs mod‐severe

Depression (SCL‐90)

SpecSensSpecSens

Any Psychiatric Dx:

“Lifetime”

Criterion Psych Dx:

Current YearAxis II Measures and cut‐points

Criterion Validity (%) of Depression and Non‐specific Physical Symptoms


ROC Curve: Axis II Depression Measure vs DSM Depression Diagnosis

1

2

3

0.0

00

.25

0.5

00

.75

1.0

0S

ens

itivi

ty

0.00 0.25 0.50 0.75 1.001 - Specificity

Area under ROC curve = 0.8123

1 Moderate cutpoint

2 Severe cutpoint

3 Optimal visual cutoff for moderate cutoff

Improving and Expanding Axis II - 1

2.37Gen Health Questionnaire‐28

2.920State Trait Anxiety Inventory

5.710SCL‐90RAnxiety disorders


3.212SCL‐90RSomatic Symptoms Index


4.520Center Epidemiologic Studies

3.920SCL‐90RDepressive disorders

Adj*

Std OR#

itemsMeasure

Criterion from DSM

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


1.1

10.7

depression

anxiety

6.9depressionDSM anxiety disorders

1.8

5.5

anxiety

depression

5.3anxietyDSM depression disorders

adj* ORPredictoradj* ORPredictorAugmented modelBase model

Outcome

Correlation anxiety with depression: 0.8



1.13.2SCL obsessive

1.54.8SCL interpersonal sensitivity

1.23.9SCL paranoia

2.07.7SCL hostility

‐‐7.1SCL anxiety

‐‐3.0SCL non‐specific physical symptoms

‐‐8.4SCL depression

Add depression: adj* OR

adj * OR

Predictor


Dependent variable: pain-related interference (MPI)

Core Axis II for DC/TMD

90+Total Number of Items10SCL-anxiety1Anxiety symptoms

20SCL-depression1Depressive sxs

Emotional Function

TBDSelf-reported syndrome checklist (e.g., other pain conditions)

1Co-morbid syndromes

12SCL-somatization1Co-morbid physical symptoms

4Graded Chronic Pain Scale1General

21Oral Behaviors Checklist2Parafunctional

20Jaw Functional Limitations Scale1Jaw behavior

Function3Graded Chronic Pain Scale1Pain

# itemsRecommended MeasureRatingConstruct

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

Problems with RDC/TMD Axis II

• Difficulty in using the screeners in general treatment setting– too long (depression)

– hard to interpret (non‐specific physical symptoms)

– too specific (Graded Chronic Pain Scale)

• Clinical application of findings from Axis II

• Integration of Axis II with Axis I

Integrated Assessment Model

General dental treatment setting• Red & yellow flags (from interview)• Distress screener• Social disability screener

Research setting• [Core Axis II measures]• Supplemental Axis II • [Developmental Axis II]

Referral clinical setting• Core Axis II measures, OR• Comprehensive pain screener

Pain psychology setting• Core Axis II measures• Supplemental Axis II

Tailored AssessmentInitial or returning complainant patient

Distress and social disability screeners

Clinical evaluationHistory for yellow flagsReview screener responses

Significant yellow flags?

Red flags?Investigate

or refer

Investigate or refer

Treatment cycle and scheduled review

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

ChronicityFunctional limitationDiscrepancy in findingsMedication overuseInappropriate • behavior• expectations• treatment response

Psychosocial red flags

yes

Distress screener: PHQ‐9Item Content

• Loss of interest or pleasure

• Low mood or hopeless

• Poor sleep

• Low energy

• Problems with appetite

• Poor self‐esteem

• Poor concentration

• Agitation or retardation

• Suicidal ideation

Rating ScaleLast 2 weeks…•Not at all• Several days •More than half the days •Nearly every day

For any POSITIVE responses:• impact on yourself or others?

Rating Scale•Not difficult at all• Somewhat difficult •Very difficult• Extremely difficult

Distress screener: PHQ‐9Psychometric Properties

Sample: 6000 primary care patients

Reference standard: structured interviews

88%, 88%Sens, spec (cutoff > 10)

< 1Clinician time to review (minutes)

‐1.33 – 0.47Sensitivity to change (effect size range)*Utility

Strong assocs: dis days, sx disability, physician visits

95 – 68%

84 – 95%

Sensitivity range

Specificity rangeValidity

0.84Temporal stability @ 48 hrs (Pearson corr)

0.89Internal consistency (Cronbach‐alpha)Reliability

StatisticParameterDomain

Kroenke, J Gen Intern Med, 2001* Lowe, J Affective Disorders, 2004

Summary

• Axis II (1992): Reliable, valid, and sufficient utility for use as a screener

• Revised Axis II for DC/TMD– ~100 items for comprehensive assessment

• Integrated assessment model– Start with screeners, escalate to full instrument sets – Use of PHQ‐9 as primary distress screener– Social disability screener: To be developed

• Tailored assessment– Identify psychosocial yellow flags from history of complaint, integrate into decision‐making

• Further developments– Develop additional axes– Apply ontologic principles to Axis II constructs

AcknowledgmentsValidation Project

• University of Minnesota: Mansur Ahmad, Gary Anderson, QuintinAnderson, Mary Haugan, Amanda Jackson, Pat Lenton, John Look, Wei Pan, Eric Schiffman, Feng Tai.

• University at Buffalo: Leslie Garfinkel, Yoly Gonzalez, Patricia Jahn, Krishnan Kartha, Sharon Michalovic, Richard Ohrbach, Theresa Speers.

• University of Washington: Sam Dworkin, Joanne Harman, Lars Hollender, Kimberly Huggins, Lloyd Mancl, Julie Sage, Kathy Scott, Earl Sommers, Jeff Sherman, Judy Turner, Edmond Truelove.

• NIH/NIDCR – U01‐DE013331

JOR‐CORE Disability Workgroup: Justin Durham, Anat Gavish, Jordi Martinez‐Gomis, Richard Ohrbach, Yoshihiro Tsukiyama, Wataru Tachida.

Miami Consensus Workshop

• General members: Gary Anderson, Sharon Brooks, Werner Ceusters, Terri Cowley, Don Denucci, Mark Drangsholt, Dominic Ettlin, Charly Gaul, Yoly Gonzalez, Jean‐Paul Goulet, Lars Hollender, Rigmor Jensen, John Kusiak, Antoon deLaat, Reny deLeeuw, Thomas List, Frank Lobbezoo, John Look, Bill Maixner, Ambra Michelotti, Greg Murray, Don Nixdorf, Sandro Palla, Arne Petersson, Eric Schiffman, Barry Smith, Peter Svensson, Corine Visscher, Joanna Zakrzewska.

• Biobehavioral Workgroup: Sam Dworkin, Lou Goldberg, Jennifer Haythornthwaite, Mike John, Marylee van der Meulen, Richard Ohrbach, Paul Pincion.

• International RDC/TMD Consortium Network

• IASP Orofacial Pain SIG

• Canadian Institute for Health Research

• National Center for Biomedical Ontology

• Medtech

RDC/TMD and DC/TMD 2010: where are we and where to we go from here?

Mark Drangsholt DDS, PhDMark Drangsholt DDS, PhD

Oral Medicine/Dental Public Health SciencesOral Medicine/Dental Public Health SciencesSchool of DentistrySchool of Dentistry

University of WashingtonUniversity of WashingtonSeattle, WA, USASeattle, WA, USA

July 16, 2010

What are the overall objectives of diagnosis?

Detecting or excluding disorders

Contributing to further diagnostic or therapeutic management

Assessing prognosisAssessing prognosis

Monitoring clinical courseMonitoring clinical course

Measuring general health or fitnessMeasuring general health or fitness

Knotterus, 2003

What are the overall objectives of diagnosis in TMD pain?

Detecting or excluding disorders – Headache from TMD, pulpitis from TMD?

Contributing to further diagnostic or therapeutic management – e.g. use NSAID or TCA medication?

Assessing prognosisAssessing prognosis –– pain likely to resolve or only pain likely to resolve or only decrease somewhat?decrease somewhat?

Monitoring clinical courseMonitoring clinical course –– TMD pain improving, TMD pain improving, declining, the same?declining, the same?

Measuring general health or fitnessMeasuring general health or fitness –– overall quality of overall quality of life of personlife of person

Overall model of diagnostic reference standard

Questionnaire Examination Diagnostic Tests+ +

Increasing accuracy

Increasing burden of time, money, invasiveness

Reference standard

Overall model of diagnostic scheme

Questionnaire Examination Diagnostic Tests+ +

Increasing accuracy

Increasing burden of timecost,

invasiveness

ShortQuestionnaire

ExaminationQuestionnaire +

ShortQuestionnaire

ShortExamination+

Reference standard

Goal is to find the simplest, least invasive, least expensive & most accurate test

Phases of Therapeutic research

Phase I Phase I –– safety, dosing in humanssafety, dosing in humans

Phase II Phase II –– TxTx in ideal circumstancesin ideal circumstances

Phase III Phase III –– TxTx in usual circumstancesin usual circumstances

““Phase IVPhase IV”” –– TxTx in routine practicein routine practice

thousands

hundreds

tens

ones

Numbers of studies

RCT

RCT

Controlled Trial

Case - Reports…

Study design

Phases of Diagnostic research

Phase I Phase I –– DxDx factor in patients, factor in patients, normalsnormals

Phase II Phase II –– DxDx in ideal circumstancesin ideal circumstances

Phase III Phase III –– DxDx in usual circumstancesin usual circumstances

Phase IV Phase IV –– Value of Value of DxDx in routine practicein routine practice

thousands

hundreds

tens

ones

Numbers of studies

Case-Con

Cohort

Cross-Sect

RCT

Study design

Using DC-TMD in usual clinical settings is next step

Oxford levels of evidence applied to TMD diagnosis

1985 1985 –– level 5level 5-- expert opinions expert opinions

1992 1992 –– level 4 level 4 –– casecase--series, crossseries, cross--sectionalsectional

2009 2009 -- level 3 level 3 –– large scale, multilarge scale, multi--site casesite case--controlcontrol

2015? 2015? –– level 2 level 2 –– cohort?cohort?

Key to progress in diagnosis is understanding underlying mechanisms in clinical patients

Heart rhythm problems Heart rhythm problems –– from symptoms and from symptoms and signs, EKG to mapping signs, EKG to mapping electrophysiologicelectrophysiologiccurrentscurrents

NeoplasmsNeoplasms –– from describing tumors, describing from describing tumors, describing histology, to biomarker predictorshistology, to biomarker predictors

TMD pain TMD pain –– from signs and symptoms to from signs and symptoms to understanding the neural mechanisms understanding the neural mechanisms -- CNS CNS

Thank you for your kind attention

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