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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
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
JPG/FMDJPG/FMD‐‐ULUL
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
JPG/FMDJPG/FMD‐‐ULUL
* 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
JPG/FMDJPG/FMD‐‐ULUL
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
JPG/FMDJPG/FMD‐‐ULUL
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
JPG/FMDJPG/FMD‐‐ULUL
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)
JPG/FMDJPG/FMD‐‐ULUL
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
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.
JPG/FMDJPG/FMD‐‐ULUL
JPG/FMDJPG/FMD‐‐ULUL
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)
Sensitivity 0.33 / Specificity 0.94
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
Sensitivity 0.46 / Specificity 0.97
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
Sensitivity 0.54 / Specificity 0.79
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
Axis II Psychometric Properties - 2
Ohrbach et al, Journal of Orofacial Pain, 2010
Axis II Psychometric Properties - 3
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
Ohrbach et al, Journal of Orofacial Pain, 2010
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
1.67Gen Health Questionnaire‐28
3.212SCL‐90RSomatic Symptoms Index
2.97Gen Health Questionnaire‐28
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
Improving and Expanding Axis II - 2
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
* Covariates include: gender, age, study site, pain intensity, interference, Axis I dx
Improving and Expanding Axis II - 3
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
* Covariates include: gender, age, study site, pain intensity, interference, Axis I dx
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