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)
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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.
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
JPG/FMDJPG/FMD‐‐ULUL
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
JPG/FMDJPG/FMD‐‐ULUL
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
JPG/FMDJPG/FMD‐‐ULUL
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
JPG/FMDJPG/FMD‐‐ULUL
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
JPG/FMDJPG/FMD‐‐ULUL
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
JPG/FMDJPG/FMD‐‐ULUL
…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
JPG/FMDJPG/FMD‐‐ULUL
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.
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
• 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.
• 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
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