MISS JULIA LAM (Orcid ID : 0000-0001-5390-9259)

Article type : Original Article

Accepted Article
Original Article

Diagnostic Criteria for Temporomandibular Disorders: diagnostic

accuracy for general dentistry procedure without mandatory
commands regarding myalgia, arthralgia and headache attributed to
temporomandibular disorder

Catharina Österlund1, Hannes Berglund2, Madeleine Åkerman2, Evelina Nilsson1, Hanna

Petersson1, Julia Lam2, 3*, Per Alstergren2, 3, 4, 5

1
Umeå University, Faculty of Medicine, Department of Odontology, Clinical Oral Physiology, Umeå,
Sweden;
2
Malmö University, Faculty of Odontology, Orofacial Pain and Jaw Function, Malmö, Sweden;
3
Scandinavian Center for Orofacial Neurosciences (SCON), Malmö, Sweden;
4
Skåne University Hospital, Specialized Pain Rehabilitation, Lund, Sweden;
5
International Network for Orofacial Pain and Related Disorders Methodology (INfORM).

*Corresponding Author: Julia Lam, julia.lam@mah.se

Running head
DC/TMD procedure without mandatory commands

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/joor.12643
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 Abstract
Background
Accepted Article
The clinical examination in Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) is a strict
procedure and comprise mandatory commands. However, learning and using these mandatory
commands in general practice have proven to be difficult and their use of DC/TMD is minimal.

Objectives
To investigate if reliability on a diagnostic level for DC/TMD diagnoses differ between examiners
using the mandatory commands or not.

Methods
Six examiners were divided into two groups: one using the mandatory commands in DC/TMD for the
clinical examination and one that did not use the mandatory commands. A reliability assessment
was performed twice, one occasion for each group of examiners. The assessment was performed
according to the guidelines from the International Network for Orofacial Pain and Related Disorders
Methodology. Each group of examiners thereby examined 16 subjects (11 TMD patients and 5
healthy individuals) each and the diagnostic agreement (reliability) as compared to diagnoses
derived by a Reference Standard Examiner were calculated with Cohen’ s Kappa coefficient.

Results
The DC/TMD diagnoses myalgia, arthralgia and headache attributed to TMD were included in the
reliability assessment. There was no significant difference regarding diagnostic agreement reliability
between the examiners using or not using the mandatory DC/TMD commands.

Conclusions
This study indicates that not using the mandatory commands in DC/TMD in general practice does
not impair the diagnostic reliability regarding the diagnoses myalgia, arthralgia and headache
attributed to TMD compared to including the commands.

Key words
Diagnostic Techniques and Procedures; Facial Pain; Headache; Myofascial pain; Pain;
Temporomandibular Joint Dysfunction Syndrome

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 Introduction
Diagnostic Criteria for Temporomandibular Disorders
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Temporomandibular disorders (TMD) is a term that describes a heterogeneous collection of
musculoskeletal diseases and conditions that affects the jaw system. Pain, usually chronic, is a very
common symptom as is dysfunction of the complex jaw system.

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) was developed by the
International Network for Orofacial Pain and Related Disorders Methodology (INfORM).1 The criteria
for each diagnosis in the DC/TMD is based on a vast amount of data collected during many years, for
example in the Validation project.1 The DC/TMD is intended for use in both clinical settings and
applied research settings.1 One important purpose of the DC/TMD and as required by the National
Institute of Dental and Craniofacial Research (NICDR, National Institutes of Health, Bethesda, MD,
USA), is to provide high-quality diagnostic criteria for use in general dentistry.

The DC/TMD diagnostic system comprises two axes; axis I for clinical conditions and axis II for
psychosocial factors. The axes contribute to an extensive and comprehensive evaluation of the TMD
patient2 according to the biopsychosocial model of chronic pain.3 Axis I covers the most common
TMD diagnoses: myalgia, myofascial pain, arthralgia, headache attributed to TMD, degenerative
joint disease and disc displacements. The diagnoses are derived from a combination of patient-
reported data and data from the clinical examination. Assessment of axis II consists of a set of
validated questionnaires, including a pain drawing and questionnaires about depression, anxiety,
stress and catastrophizing.1

The clinical examination in DC/TMD is based on a strict and detailed description of how all steps in
the clinical examination are to be performed. Most steps require communication with the patient
and in DC/TMD this communication comprise mandatory commands. However, learning, adopting
and using these mandatory commands in daily general practice have proven to be very difficult. As a
consequence, the important use of DC/TMD in general practice is more or less forgone. 4,5

The aim of this study was to investigate if reliability on a diagnostic level for DC/TMD diagnoses
differ between examiners using the mandatory commands in DC/TMD or not in general practice.

Materials and Methods

This study is a collaboration between the Faculty of Odontology, Malmö University (MaU) and the
Department of Odontology, Faculty of Medicine, Umeå University (UmU). Both MaU and UmU teach
DC/TMD as part of their respective undergraduate dental curricula in Orofacial Pain and Jaw
Function and require the students to use DC/TMD in their clinical training.

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 At the time of the reliability assessments, the MaU and UmU students had seen and examined a
comparable number of patients and had comparable amount of time for clinical training (about four
h/week during 1.5 semester) in the specialty of Orofacial Pain and Jaw Function.
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Examiners
At MaU, an undergraduate student group with ten members that had learnt the DC/TMD procedure
but without a requirement to learn the mandatory commands was used as the test group. In the
beginning of the clinical course in Orofacial Pain and Jaw Function the student group was informed
that they were not to learn the mandatory commands. However, the students theoretically learned
the information needed to correctly communicate to the patient as defined in DC/TMD (i.e. “pain”,
“familiar pain”, “…during the last 30 days”). This was done without teaching the mandatory
commands. The students were also informed that their participation was voluntary. All students
agreed to participate. The students were examined regarding their knowledge and skills in the
clinical procedure in DC/TMD before beginning examining patients in their undergraduate course.
Three students were then randomly selected by lottery from this group for the reliability
assessment, four weeks before the reliability assessment. The examiners comprised two men and
one woman with an age of 24, 25 and 27 years.

At UmU, a student group with 24 members that had fully learned and passed a clinical examination
of the DC/TMD including the mandatory commands was used as the control group. Students that
had the possibility to participate were asked for interest to participate. All students agreed to
participate. Three examiners were then selected from this group randomly by lottery for the
reliability assessment, four weeks before the reliability assessment. The examiners comprised two
women and one man with an age of 22, 23 and 31 years.

The Reference Standard Examiner (RSE; JL) was a highly trained and calibrated individual approved
by the INfORM for DC/TMD in Swedish. Also, a specialist in orofacial pain and jaw function
(OFP/TMD) responsible for the DC/TMD Training and Reliability Center in Malmö, Sweden, assumed
the role as Protocol Supervisor (PS; PA) to inform and calibrate examiners throughout the reliability
assessment days. These RSE and PS individuals participated in both Umeå and Malmö and the
procedure for reliability assessment was performed according to INfORM guidelines.6

Patients and healthy individuals

This study involved convenience samples of a total of 22 patients referred for OFP/TMD examination
and treatment to MaU and UmU as well as 10 healthy individuals (Table 1). The inclusion criteria for
the patients were participants presenting with OFP/TMD symptoms, i.e. answered “Yes” on at least
one of the questions ‘Do you have pain in your temple, face, jaw or jaw joint once a week or more?’
or ‘Do you have pain once a week or more when you open your mouth or chew?’7 or healthy
individuals without current or previous OFP/TMD symptoms that answered “No” on these two

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 questions. Exclusion criteria for both groups were individuals with age below 18 years and severe
physical disease with American Society of Anesthesiologists (ASA) class ≥ 3 (cardiovascular, renal,
pulmonary or autoimmune disease or malignancy), psychiatric disease (bipolar disorder, ADHD,
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autism spectrum disorders, anorexia nervosa, bulimia nervosa, schizophrenia and personality
disorders whereas depression or anxiety disorders did not exclude the subject).

Before the examination all patients and healthy individuals answered the DC/TMD Axis II
instruments used for assessment of psychosocial status and distress as well as the Symptom
Questionnaire required for DC/TMD axis I diagnostics. The demographic characteristics of the
sample regarding each group are described in Table 1. There was no significant difference between
the two groups regarding demographic variables. The subjects were informed about the project and
signed a consent form. The project was approved by the regional Ethical Review Board in Lund,
Sweden, conducted in accordance with the World Medical Association’s Declarations of Helsinki and
the Standards for reporting of diagnostic accuracy studies (STARD) 2015 guidelines8 was adopted to
the largest possible extent where applicable.

Sample sizes were chosen to establish sufficient tolerance of repeated examination procedures for
each patient and to enable useful clinical data to emerge, as determined in published reports of
RDC/TMD assessments.9-11 The sample sizes used were also based on previous studies9-12 that also
included establishment of reliability of DC/TMD clinical examiners in distinguishing signs and
symptoms of TMD. That was out of the scope of the present study which focuses on the diagnostic
level.

Clinical examination
The DC/TMD clinical examination assesses pain and headache location(s), range of jaw movements
and familiar jaw movement pain, joint noises and familiar palpatory pain over the temporal and
masseter muscles and over the temporomandibular joint (TMJ).1

A recorder that registered the clinical findings was present in each examination room and stayed
with the subjects. Recorders were recruited from undergraduate dental students that were trained
in recording DC/TMD clinical examination data prior to the reliability assessment.

Reliability assessment
The reliability on a diagnostic level of DC/TMD Axis I diagnoses, based on the DC/TMD Symptom
Questionnaire and clinical examination, was assessed during one full day (April 25, 2017) at MaU and
one full day, one week later, at UmU (May 2, 2017). The examiners individually examined all patients
and healthy individuals, blinded from each other’ s findings and from whether the subject was a
patient or healthy individual. An incomplete Latin square design was used such that the order of the

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 examiners was randomized to balance and minimize examiner’s examination order effects. The
reliability assessment was performed in four two-hour blocks of DC/TMD clinical examinations. Each
examination was performed over a maximum of twenty minutes in order to allow the subject to rest
Accepted Article
at least ten minutes between examinations. The examiners moved between the participating
patients and healthy individuals, with the patient/healthy individual remaining seated in the same
clinical operatory. A recorder was assigned to each operatory.

All instructions to patients and healthy individuals and questionnaires were in Swedish. The
examiners at UmU and the RSE (both at MaU and UmU) used the standardized translations
produced by DC/TMD Training and Reliability Center in Malmö, Sweden in accordance to accepted
standards for producing such translations as required and adopted by the INfORM.13

Protocol supervisor observation and feedback

As described in the INfORM guidelines for DC/TMD training and reliability assessment, the PS
observed one examiner at a time during the clinical examinations and covered during the day all
examiners, including the RSE. After each clinical examination, the PS gave feedback to the examiner
about what was observed by the PS. After each two-hour block, the PS recorded feedback from the
subjects and recorders at UmU regarding any differences between the examiners related to
instructions and commands as well as procedures. At MaU, the PS recorded feedback from the
subjects and recorders regarding differences between the examiners related to procedures. This was
summarized and forwarded to the examiners after each two-hour block.

Diagnostic criteria
Data from the DC/TMD clinical examination were combined with anamnestic data from the
Symptom Questionnaire in order to derive DC/TMD diagnoses by the use of the DC/TMD diagnostic
algorithms and criteria.1 The patients were diagnosed independently by two of the authors and any
discrepancies were discussed until consensus was reached. The following DC/TMD Axis I diagnoses
were derived where possible:

Pain-related TMD and headache (sensitivity, specificity)

Myalgia (per subject; 0.90, 0.99)
Arthralgia (per joint; 0.89, 0.98)
Headache attributed to TMD (per subject; 0.89, 0.87)

Intra-articular joint disorders and degenerative joint disorder (sensitivity, specificity)

Degenerative joint disease (per joint; 0.55, 0.66)
Disc displacement with reduction (per joint; 0.34, 0.92)
Disc displacement with reduction with intermittent locking (per joint; 0.38, 0.98)
Disc displacement without reduction with limited opening (per joint; 0.80, 0.97)
Disc displacement without reduction (per joint; 0.54, 0.79)

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 Statistics
For descriptive statistics, median and 25th/75th percentiles are presented. The significance of
differences between the groups with and without the mandatory commands was calculated with the
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Mann-Whitney U-test. The significance of the difference in distribution of derived diagnoses in the
groups using the mandatory commands or not using them was calculated with the Chi-square test.

The diagnoses derived from the clinical data from the examiners, i.e. based on responses to the
questionnaires as well as data from the clinical examination, were individually compared to those
derived from the RSE clinical data. The Cohen's kappa coefficient was used to calculate the degree of
agreement between each examiner and the RSE regarding each DC/TMD diagnosis as a measure of
reliability on a diagnostic level. TMJ specific diagnoses were treated as independent observations,
i.e. two possible diagnoses per individual: one for the left and/or one for the right TMJ. Kappa values
as follows were interpreted as: < 0: less than chance agreement, 0.01 - 0.20: slight agreement, 0.21 -
0.40: fair agreement, 0.41 - 0.60: moderate agreement, 0.61 - 0.80: substantial agreement and 0.81 -
0.99: almost perfect agreement.14,15 Statistics were performed using Stata software, version 13-SE
(Stata Corp., College Station, TX, USA).

The significance of differences in reliability between examinations performed with and without the
mandatory commands was calculated with the Mann-Whitney U-test for each diagnosis.

A probability level of P < 0.05 was considered as significant.

Results
The distribution of the DC/TMD diagnoses myalgia, arthralgia, headache attributed to TMD,
degenerative joint disease and disc displacement are reported in Table 2. The prevalences of
degenerative joint disease and disc displacement diagnoses in the study sample were considered too
low to be included in the reliability assessment (Table 2).

Fig.1 shows the individual Kappa values for the examiners per included DC/TMD diagnosis and with
and without using the mandatory commands, compared to the RSE.

The agreement for myalgia was significantly higher without than with mandatory commands (p =
0.025). There was no other significant difference in diagnostic agreement between the groups using
the commands or not using them.

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 Discussion
This study indicates that the DC/TMD procedure for general dentistry without using the mandatory
commands does not impair the diagnostic reliability regarding the diagnoses myalgia, arthralgia and
Accepted Article
headache attributed to TMD compared to using the mandatory commands as defined in DC/TMD.

The present study investigated if not using the mandatory commands during the clinical DC/TMD
examination would result in impaired diagnostic performance compared to the same clinical
examination but with the mandatory commands. The diagnostic performance of the examiners that
did not use the mandatory commands were compared to a highly trained RSE and to examiners that
trained to use the mandatory commands. Most examiners reached an “almost perfect agreement”
with the RSE for these diagnoses. Two observations of agreement showed “substantial agreement”.
The results support that a DC/TMD clinical examination without using the mandatory commands
does not result in impaired diagnostic performance regarding the diagnoses myalgia, arthralgia and
headache attributed to TMD.

The mandatory commands require learning and practice time to fully master. In a specialist setting,
these commands work very well and have been used, for example at the Orofacial Pain Unit at MaU,
Sweden, since 2012. However, the mandatory commands seem at the same time to be a too big a
barrier for general practitioners to learn in order to adopt DC/TMD in their daily practice. This is
based on experience from numerous lectures and courses in DC/TMD given to general practitioners
(a cautious estimate of number of dentists participating in all these lectures and courses since 2014:
>400) given by the DC/TMD Training and Reliability Center in Malmö, Sweden.

What does this mean for the future direction of implementation of DC/TMD in general dentistry?
There are, today, already plans to try to streamline DC/TMD in order to increase its adoptability in
general practice. The findings in the present study may be regarded as a support to consider
omitting the mandatory commands in that process for general dentistry.

Examiners not using the mandatory commands showed a statistically significant better agreement to
the RSE than did the examiners using the commands for myalgia. However, we do not consider this
difference to be of any clinical significance since it was due to a diagnosis discrepancy in a single
patient.

The agreement between the examiners and the reference standard examiner was somewhat lower
for arthralgia than for myalgia and headache attributed to TMD. This is in agreement with findings
from for example Vilanova et al. (2015).12 In that study, the lowest agreement for arthralgia was
considered to be due to lack of formal training in DC/TMD, i.e. solely self-teaching. For the groups
that went through the two-day DC/TMD course in that study, the agreement for arthralgia was

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 slightly lower than for example myalgia, as in the present study. The examiners in our study had
learnt DC/TMD thoroughly as part of their undergraduate training and had used DC/TMD to assess
their undergraduate patients. Also, the examiners had to pass an examination of their knowledge
Accepted Article
and skills in DC/TMD before they could see patients in their undergraduate clinical training. This was
very similar in MaU and UmU why the lower agreement in arthralgia is most probably reflects
difficulties in assessing TMJ pain.

There is a considerably coexistence of myalgia and arthralgia in TMD patients. For example, only
7.2% of 614 TMD patients show only arthralgia and 7,7% only myalgia whereas 73% fulfill both
diagnoses.16 The TMJ is located deep under the skin, parotid gland, muscle fascia´s, ligament, vessels
and nerves etc why manipulation of the TMJ with movement or palpation also results in substantial
influence on these tissues as well. Taken together, the difficulties to examine the TMJ, as well as
difficulties for the patient to exactly locate the pain to the TMJ proper, may explain the somewhat
lower agreement for arthralgia.

Degenerative joint disease and disc-related disorders were excluded from the data analysis, although
anamnestic and clinical examination data were collected for these diagnoses. This was necessary
due to the very low number of positive observations, which prevented any relevant statistical
analysis of agreement between the examiners.

In addition to the mandatory commands, the clinical examination in DC/TMD is based on a strict and
detailed description of how all steps in the clinical examination are to be performed and in which
order. Some degree of training/learning of the examined subject through the four examinations that
each subject was subjected to can not be ruled out. However, we performed the reliability
assessment strictly according to the guidelines from INfORM that included randomized order of
examinators.6

The examiners included in the present study were all dental students at their third or fourth year of
studies in Malmö and Umeå. We choosed to include these students since they were systematically
taught DC/TMD in the same way and, at the time of the reliability assessment, they had very similar
clinical experience of using DC/TMD. They neither had any previous experience from any other
diagnostic procedure of TMD. We therefore consider the included examiners to be very similar,
except for the training in the mandatory commands. This strengthens this study considerably.

This study did not systematically quantify the potential differences of what actually was said with
and without the mandatory commands since that was out of the main scope of the study. With the
information reported in this study, it is not possible to tell how much the verbal constructs may
differ from the mandatory commands in order to obtain the same diagnostic results. However,

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 interesting observations were made from the post-examination interview of patients and recorders
where the PS collected information regarding any differences between the examiners related to
instructions and commands as well as procedures. Interviews revealed minor and subtle differences
Accepted Article
in communication clarity between the examiners in both the group with mandatory commands and
the group without the mandatory commands. These differences were, in addition, unrelated to the
examination order. Further, in the examiner group with three examiners not using the mandatory
commands, the reference standard examiner (who used the mandatory commands) was perceived
by one patient to be somewhat more thorough but also more “robot-like”(data not shown).

Conclusions
This study indicates that not using the mandatory commands in DC/TMD in general practice does
not impair the diagnostic reliability regarding the diagnoses myalgia, arthralgia and headache
attributed to TMD compared to including the commands.

Acknowledgements
The project was approved by the regional Ethical Review Board in Lund, Sweden (Dnr 2017/195) and
was supported by institutional funding at Malmö University and Umeå University as a joint project.

The authors wish to thank the participating students (examiners as well as recorders) and, at least as
much, the participating patients and healthy individuals.

Disclosure
Author Per Alstergren is the chair of the DC/TMD Training and Reliability Committee within the
INfORM network that maintains and develops DC/TMD. The other authors have stated explicitly that
there are no conflicts of interest in connection with this article.

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Accepted Article

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Accepted Article

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 Figure legends
Figure 1
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Scatter-plot showing the individual degree of agreement (Cohen’s kappa values) for each examiner,
compared to the reference standard examiner, in the two groups examined according to the
Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) with or without using the
mandatory commands to the subjects. In each group, 11 patients with TMD symptoms and five
healthy individuals were examined. The examiners had comparable education in and experience of
clinical use of DC/TMD. Three examiners used the mandatory commands whereas three did not. The
reference standard examiner was a highly trained and calibrated examiner approved by the
International Network for Orofacial Pain and Related Disorders Methodology (INfORM).

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