CLINICAL RESEARCH

Iryna H. Daline, DMD, MSD,

Diagnostic Accuracy of a MS,* Gary D. Slade, BDSc,
DDPH, PhD,†‡§ Ashraf F. Fouad,
Temporomandibular Disorder DDS, MS,¶ Donald R. Nixdorf,
DDS, MS,k** and
Pain Screener in Patients Inna E. Tchivileva, MD, MS†††

Seeking Endodontic Treatment

for Tooth Pain

ABSTRACT
SIGNIFICANCE
Introduction: This study assessed the accuracy of a TMD Pain Screener questionnaire in
identifying patients with temporomandibular disorder (TMD) pain among those seeking TMD pain often coexists or
endodontic treatment for tooth pain. It also investigated whether the screener accuracy could contributes to the chief
be improved by adding questions regarding putative predictors of TMD status. complaint in patients with tooth
Methods: One hundred patients seeking endodontic treatment for tooth pain were enrolled. pain. The 6-question TMD Pain
Participants completed the 6-question TMD Pain Screener before treatment. A Screener, coupled with a
board-certified orofacial pain specialist/endodontic resident conducted endodontic and TMD current pain intensity rating, is
examinations using validated Diagnostic Criteria for TMD (DC/TMD). The sensitivity (Se), the most accurate currently
specificity (Sp), and positive/negative predictive values (PPVs/NPVs) were calculated for the available TMD screening tool
6-question and 3-question versions of the TMD Pain Screener. Logistic regression and for endodontic patients
receiver operating characteristic curve (AUROC) analyses were performed to determine the experiencing toothache.
screening accuracy. Results: At the screening threshold of
3, TMD Pain Screener’s
sensitivity was 0.85, specificity 0.52, PPV 0.68, and NPV 0.75 for the 6-question version and
0.64, 0.65, 0.69, and 0.61, respectively, for the 3-question version. The AUROC was 0.71
From the *Division of Comprehensive Oral
(95% CL: 0.61, 0.82) and 0.60 (95% CL: 0.48, 0.71) for full and short versions, respectively.
Health–Endodontics, †Center for Pain
Adding a rating of current pain intensity of the chief complaint to the screener improved the Research and Innovation, ‡Division of
AUROC to 0.81 (95% CL: 0.72, 0.89) and 0.77 (95% CL: 0.67, 0.86) for full and short versions, Pediatric and Public Health, and ††Division
of Oral and Craniofacial Health Sciences,
respectively, signifying useful overall accuracy. Conclusions: The 6-question TMD Pain
Adams School of Dentistry, University of
Screener, combined with the patient’s rating of current pain intensity of the chief complaint, North Carolina at Chapel Hill, Chapel Hill,
could be recommended for use in endodontic patients with tooth pain for detecting painful NC; §Department of Epidemiology,
Gillings School of Global Public Health,
TMD. (J Endod 2024;50:55–63.)
University of North Carolina, Chapel Hill,
NC; ¶Department Endodontics, University
KEY WORDS of Alabama at Birmingham, Birmingham,
AL; and kDivision of TMD and Orofacial
Temporomandibular disorders; pain; screening; diagnostic validity; root canal therapy Pain, Department of Diagnostic and
Biological Sciences, School of Dentistry,
and **Department of Radiology, Medical
School, University of Minnesota,
Pain from temporomandibular disorders (TMDs) can mimic or coexist with dental pain, complicating the
Minneapolis, MN
initial and/or postoperative endodontic diagnosis1-5. A recent study found a high TMD pain prevalence
Address requests for reprints to Inna E.
(54%) among patients seeking endodontic evaluation and treatment for tooth pain6. TMD pain did not
Tchivileva, Division of Oral and Craniofacial
affect endodontic pain in the majority of these patients, but it contributed to the chief complaint in 20% Health Sciences, UNC-CH Adams School
and was the sole source of pain in 8%6. Another study showed that, in 42% of patients, persistent “tooth” of Dentistry, 5509 Koury Oral Health
pain after root canal treatment (RCT) was completely or partially attributed to TMD4. Considering the high Sciences Building, Campus Box #7455,
prevalence of TMD pain in endodontic patients with a complaint of tooth pain, routine TMD assessment is Chapel Hill, NC 27599-7455.
E-mail address: inna_tchivileva@unc.edu
crucial for accurate and comprehensive diagnosis. However, performing full TMD examination according 0099-2399/$ - see front matter
to the validated Diagnostic Criteria for TMD (DC/TMD)7,8 is time-consuming and may not be feasible in a
Copyright © 2023 American Association
busy endodontic practice. of Endodontists.
Using a validated screening questionnaire could help identify patients who require comprehensive https://doi.org/10.1016/
TMD assessment and guide differential diagnostic procedures to locate the source of pain. However, j.joen.2023.10.011

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creating an effective screener for this
population is challenging because patients do
not distinguish well between jaw and tooth
pain6,9,10. The TMD Pain Screener has shown
promise and high accuracy in identifying TMD
pain patients in convenience samples at
healthcare institutions11. However, diagnostic
accuracy of a screening tool may vary in
different populations12-14. Patients referred to
endodontists may have a complex pain
presentation with potential overlap between
tooth and jaw symptoms as well as other co-
morbid orofacial pain diagnoses, compared
with general population or patients seen in
general dentistry offices. However, testing of
the TMD Pain Screener to date has been
limited to studies that either excluded patients
with tooth pain11 or did not compare screening
responses to findings from DC/TMD
examinations in endodontic patients15.
To overcome the above-mentioned
gaps and shortcomings, our study aimed to
measure sensitivity, specificity, predictive
values, and area under the receiver operating
characteristic curve (AUROC) of the 6-question
and 3-question versions of the TMD Pain
Screener in patients having tooth pain in the
preceding month and seeking endodontic
evaluation and nonsurgical root canal
treatment (NS-RCT) or retreatment. The
secondary aim was to assess whether
combining the screener with known predictors
of TMD status would improve its performance.
MATERIALS AND METHODS
Study Design
This was a cross-sectional study where data
collection was planned before the
administration of the TMD Pain Screener and
DC/TMD examination. One hundred patients
were recruited in Endodontic Emergency
Clinic, Endodontic Graduate Clinic, and
Endodontic Dental Faculty Practice at the
University of North Carolina (UNC) Adams
School of Dentistry between October 2020
and December 2021. All regulatory practices
required by the university were followed, which
included an institutional review board (IRB)
approval (permission #20-1706) and a written
informed consent of patients participating in
this study.
Participants
Participant eligibility criteria for enrollment were
as follows:
1. Eighteen years old or older, and
2. Scheduled for an endodontic evaluation
and/or NS-RCT or retreatment, and
3. Patient’s self-report of experiencing tooth
pain (
1 on a 0-10 numeric rating scale
56 Daline et al.
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(NRS)) in the preceding 30 days as one of
the reasons for referral to an endodontic
clinic.
Exclusion criteria were one or more of:
1. Periodontal or oral mucosa pain;
2. Asymptomatic patient referred for elective
NS-RCT, NS-RCT due to an incidental
finding or a mechanical pulpal exposure;
3. Previous endodontic treatment of the tooth
in question within the preceding 30 days;
4. Surgery or trauma of the head or teeth in
the past 6 months;
5. Inability to communicate in English;
6. Severe psychological distress.
Potentially eligible patients were
identified among those scheduled for an
endodontic evaluation and/or NS-RCT or
retreatment in the 3 university clinics.
Consecutive patient enrollment was performed
with a telephone call to verify their eligibility.
Eligible patients were scheduled for a research
appointment prior to their endodontic
evaluation/treatment appointment.
Assessments
The index test was the TMD Pain Screener11.
During the research visit, patients completed
the screener first and placed it in a sealed
envelope to ensure the investigator’s blinding
to the Screener’s results. A full version of the
TMD Pain Screener consists of 6 questions,
with the score ranging from 0 to 7. The score
equal or greater than 3 is considered a positive
screening result for TMD as was determined in
a previous study11 (Fig. 1). A short version of
FIGURE 1 – TMD Pain Screener. Q1-Q3d are summed to score the 6-question version of the TMD Pain Screener, while
Q1-Q3a are summed to score the 3-question version. Responses “No pain” or “No” are given 0 points, responses “From
very brief to more than a week, but it does stop” and “Yes” are given 1 point, and response “Continuous” is given 2
points. From Gonzalez et al (2011), JADA.
TMD Pain Screener contains the first 3
questions of the full version, with a maximum
score of 4 and a positivity threshold of
211.
Other standardized questionnaires were
also administered to measure characteristics
of the chief complaint and TMD pain,
psychological measures, medical history, and
pain medication use. The completed
questionnaires included the following:
1. Chief Pain Complaint Questionnaire —
containing standard questions used to
collect detailed history of present illness;
2. Graded Chronic Pain Scale Revised
(GCPS-R)16 — a validated instrument
commonly used for chronic pain
assessment, which we used to measure
TMD pain characteristics;
3. Patient Health Questionnaire (PHQ-4)17 —
a validated 4-item screener for anxiety and
depression;
4. Comorbid Medical Condition Questionnaire
— containing 28 medical and dental
diagnoses with a potential to mimic or
contribute to pain of endodontic and TMD
origin;
5. Concomitant Medications — a list of all
currently taken medications with a potential
to affect pain presentation.
Immediately after participants
completed paper questionnaires, they were
clinically examined according to the DC/TMD7
to determine presence or absence of TMD
myalgia (local myalgia, myofascial pain, and
myofascial pain with referral) or arthralgia. The
DC/TMD examination was used as a reference
standard. To establish TMD myalgia or
JOE  Volume 50, Number 1, January 2024
arthralgia, all three of the following criteria
should be met: 1) history of jaw/face pain in the
last 30 days; AND 2) pain is made worse or
better by jaw function/parafunction; AND 3)
familiar pain is reproduced by maximum
mandibular opening; OR 3) familiar pain is
reproduced by muscle and/or TMJ palpation.
TMD assessment was followed by a
standardized and thorough endodontic
examination protocol to assess caries;
discoloration; cracks and fractures; wear
patterns; restoration and its quality; swelling;
sinus tract; type of occlusion on the tooth; pain
to palpation, percussion, and Tooth Slooth;
mobility grade; periodontal probing depths;
transillumination; Endo Ice test; and electric
pulp test (EPT).
All TMD and endodontic examinations
during the research visit were conducted by a
single primary investigator (PI) [IHD], who was
both a board-certified specialist in Orofacial
Pain and a resident in the UNC Endodontics
Master’s program at the time. During the
subsequent endodontic appointment, an
attending resident/faculty performed their
independent clinical and radiographic
evaluation, diagnosis, and treatment if
indicated. The participants’ electronic patient
records were later audited by the PI to
determine definitive endodontic diagnoses
based on all available pre-, intra-, and
postoperative data. In rare cases of
disagreement between the recorded
endodontic diagnoses of the attending
clinician and the ones of the PI, a consensus
diagnosis was reached by consulting another
board-certified endodontist [AFF]. All
endodontic providers used diagnostic
terminology that follows the American Board of
Endodontists guidelines.
Sample Size Calculation
When planning this pilot study, we aimed to
recruit 100 participants based on the sample
size required for a noninferiority hypothesis that
the TMD Pain Screener questionnaire was not
appreciably inferior (beyond a margin of
acceptable inferiority) to benchmarks of 0.78
sensitivity and 0.41 specificity. Those
benchmarks were lower 95% confidence limits
(CLs) reported by Fonseca Alonso et al15 for
the 6-question TMD Pain Screener in
distinguishing between patients with TMD
versus patients with odontogenic pain. We
further assumed that at least 20% of
participants in the planned study would have
examiner-verified painful TMD, which yielded
statistical power of 80% and .99% for those
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benchmarks of specificity and sensitivity,
respectively. In fact, observed prevalence of
TMD in our sample was 54%, and posthoc
power calculations yielded power of 92% and
.99% for the same benchmarks of specificity
and sensitivity, respectively.
Data Management and Statistical
Analysis
Questionnaire data and examination results
were recorded on paper forms that were
scanned using Teleform software to create
ASCII files for data analysis. Endodontic
diagnoses were entered into an Excel
spreadsheet that had prespecified data
validation criteria. ASCII files and the Excel
datasheet were merged using SAS V9.4
software (SAS Institute Inc., Cary, NC), which
was also used for the data analysis.
For the first aim, contingency table
analysis cross-classified subjects according to
TMD Pain Screener response (positive or
negative, based on previously reported
thresholds for dichotomizing the screener
score)11 and the TMD myalgia/arthralgia status
(positive or negative)7. Sensitivity and
specificity proportions were calculated along
with their 95% Wald CLs for the binomial
proportion. Positive and negative predictive
values and Youden’s index (ie,
Sensitivity 1 Specificity minus one) were also
calculated for descriptive purposes18.
For the secondary aim, binary logistic
regression models were used to predict odds
of TMD myalgia/arthralgia. Predictor variables
were the TMD Pain Screener score alone or in
combination with variables known to be
associated with higher TMD prevalence in this
sample6. For both the 3-question and 6-
question versions of the TMD Pain Screener, 3
models were created: Model 1 used only the
screener score as the predictor variable, Model
2 added pain intensity of the chief complaint,
and Model 3 added the other previously-
identified predictors of TMD prevalence:
presence of pain to tooth percussion, time
from onset of chief complaint pain, PHQ-4
score, pain frequency of the chief complaint,
and presence of symptomatic apical
periodontitis. For each model, the receiver
operating characteristic (ROC) curve was
plotted and AUROC was calculated, along
with 95% confidence intervals (CIs). To guard
against bias from overfitting, the
“crossvalidate” option was used in the SAS
“logistic” procedure to calculate cross-
validated probabilities for the ROC statistics.
Statistical significance of the difference
between AUROCs was determined in SAS
using the "roccontrast" statement.
RESULTS
Of 197 prescreened patients, 100 met
selection criteria and were enrolled in the study
(Fig. 2). Detailed descriptive statistics and their
statistical analyses regarding characteristics of
patients and findings from tooth and TMD
examinations have been previously published6
(Fig. 2, Supplemental Tables S1, and S2).
Validity of the TMD Pain Screener
Full 6-Question Version
The full TMD Pain Screener had 85%
sensitivity, 52% specificity, 68% positive
predictive value (PPV), and 75% negative
predictive value (NPV) (Table 1). The overall
accuracy of the full screener, measured by the
AUROC, was 0.71 (95% Cl: 0.61, 0.82)
(Fig. 3A). One interpretation of the AUROC is
that a test with an area greater than 0.9 has
high accuracy, while 0.7-0.9 indicates useful
accuracy, 0.5-0.7 – low accuracy, and 0.5 is a
chance result19. Accordingly, the overall
accuracy of the full TMD Pain Screener can be
defined as useful. Another classification
provides interpretation for more categories of
the AUROC values: , 0.5—“test not useful”;
0.5-0.6—“bad”; 0.6-0.7—“sufficient”; 0.7-
0.8—“good”; 0.8-0.9—“very good”; 0.9-1—
“excellent”20.
Short 3-Question Version
Using the previously validated positivity
threshold of 211 for the short TMD Pain
Screener in our study, it had 87% sensitivity,
46% specificity, 65% PPV, and 75% NPV
(Table 1). Using the positivity threshold of 3 for
the short TMD Pain Screener, it had 64%
sensitivity, 65% specificity, 69% PPV, and
61% NPV (Table 1). One of the methods to
identify an optimal threshold for a test is the
Youden’s index21: the threshold on the ROC
curve at which the Youden’s index is
maximized is considered an optimal cut-off
point. While the values of sensitivity and
specificity were more balanced at the
threshold of 3 than at the threshold of 2 for the
short screener, the Youden’s index at the
threshold of 3 was lower than at the threshold
of 2 (0.29 vs 0.33, respectively), indicating the
threshold of 2 to be a more optimal cut-off
point. For the short TMD Pain Screener, the
AUROC of 0.60 (95%CL: 0.48, 0.71) indicated
lower overall accuracy compared with the full
TMD Pain Screening in Endodontics 57
FIGURE 2 – Flow of participants. TMD, temporomandibular disorders; NP, normal pulp; RP, reversible pulpitis; SIP, symptomatic irreversible pulpitis; AIP, asymptomatic irreversible
pulpitis; PN, pulp necrosis; PIT, previously initiated treatment; PT, previously treated; NAT, normal apical tissues; SAP, symptomatic apical periodontitis; AAP, asymptomatic apical
periodontitis; AAA, acute apical abscess; CAA, chronic apical abscess; CO, condensing osteitis.

version which had the AUROC of 0.71 (95%
Cl: 0.61, 0.82) (Fig. 3B).
Predictors Used to Improve Overall
Accuracy of the TMD Pain Screener
To investigate whether the overall accuracy of
the TMD Pain Screener could be improved
with addition of other predictors, we evaluated
6 characteristics that were previously reported
as positively associated with prevalence of
painful TMD in endodontic patients6. These
characteristics were as follows: current pain
intensity of the chief complaint (pain rated on a
NRS 0-10 as of right “now”, as opposed to the
average pain rating over the past month), pain
frequency, time from the pain onset, pain to
tooth percussion, psychological distress
measured by PHQ-4, and a diagnosis of
symptomatic apical periodontitis (Table 2). All
these predictors were moderately correlated
with the score of the full TMD Pain Screener,
except the current pain intensity of the chief
complaint (Table 3). The correlations between
the predictors and the score of the short TMD
Pain Screener were less pronounced. Because
the current pain intensity of the chief complaint
had the lowest correlation coefficients with the
scores of the full and short screeners, it was
chosen as a second predictor for multivariable
regression in Model 2 (Table 4).
Prediction of TMD Status from
Multivariable Regression Models
Results from multivariable logistic regression
models are presented in Table 4. In Model 2,
adding current pain intensity of the chief
complaint to the full version of the screener
increased the AUROC from 0.71 to 0.81 and
adding current pain intensity to the short
screener version–from 0.60 to 0.77. In Model

TABLE 1 - Diagnostic Accuracy of 6- and 3-Question Versions of the TMD Pain Screener

DC/TMD pain diagnosis

TMD pain TMD pain
screener screener cutoff Present Absent Total Sensitivity (95% CL) Specificity (95% CL) PPV (95% CL) NPV (95% CL)
6-question
3 points 46 22 68 0.85 (0.76, 0.95) 0.52 (0.38, 0.67) 0.68 (0.57, 0.79) 0.75 (0.60, 0.90)
version ,3 points 8 24 32
Total 54 46 100 Youden’s index: 0.37
3-question
2 points 47 25 72 0.87 (0.78, 0.96) 0.46 (0.31, 0.60) 0.65 (0.54, 0.76) 0.75 (0.59, 0.91)
version ,2 points 7 21 28
Total 54 46 100 Youden’s index: 0.33

3 points 35 16 51 0.64 (0.52, 0.78) 0.65 (0.51, 0.79) 0.69 (0.56, 0.81) 0.61 (0.48, 0.75)
,3 points 19 30 49
Total 54 46 100 Youden’s index: 0.29

95% CL, 95% Confidence Limits; DC/TMD, Diagnostic Criteria for Temporomandibular Disorders; NPV, Negative Predictive Value; PPV, Positive Predictive Value; TMD,
Temporomandibular disorders.

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 A Models for 6-question TMD Pain Screener B Models for 3-question TMD Pain Screener

1.00 1.00

0.75 0.75

Sensitivity

Sensitivity
0.50 0.50

0.25 0.25

0.00 0.00
0.00 0.25 0.50 0.75 1.00 0.00 0.25 0.50 0.75 1.00
1 - Specificity 1 - Specificity

Area Under ROC Curve (95% CL) Area Under ROC Curve (95% CL)
Model 1: 0.71 (0.61, 0.82) Model 1: 0.60 (0.48, 0.71)
Model 2: 0.81 (0.72, 0.89) Model 2: 0.77 (0.67, 0.86)
Model 3: 0.81 (0.72, 0.89) Model 3: 0.80 (0.71, 0.88)

FIGURE 3 – Receiver Operating Characteristic (ROC) curves for multivariable logistic regression models.

3, adding all predictors improved the model
performance compared with Model 1 for both
versions of the screener, but didn’t provide any
advantage over Model 2 (Table 4 and Fig. 3).
Altogether, Model 2 that included both the full
TMD Pain Screener and current pain intensity
had the highest accuracy and practicality.
To operationalize the combined use of
the full TMD Pain Screener and current pain
intensity of the chief complaint (NRS 0-10) for
patients with a history of preoperative pain in
endodontic practice, we offer a grid with
optimal combinations of positivity thresholds
for these 2 tools (Fig. 4). These optimal
combinations, determined at the maximized
Youden’s index of at least 0.5, yield useful
TMD prediction accuracy characterized by the
sum of sensitivity and specificity of at least
150%.
TABLE 2 - The Putative Predictors of the TMD Status From Univariate Logistic Regression Models
Predictor
6-question TMD Pain Screener
3-question TMD Pain Screener
Current pain‡ intensity
Pain to tooth percussion
Time from pain‡ onset
PHQ-4
Pain‡ frequency in the last 30 days
Symptomatic apical periodontitis
95% CL, 95% Confidence Limits; PHQ-4, Patient Health Questionnaire-4; OR, Odds Ratio; TMD, Temporomandibular
disorders.
*Scale of predictor variable used to calculate odds ratio: SD 5 standard deviation, binary 5 0,1.
†
OR is the estimated odds ratio from a binary logistic regression model evaluating effect of the putative predictor on odds of
TMD.
‡
Pertains to the chief pain complaint.
DISCUSSION The validity measures of screening or
diagnostic tests include sensitivity, specificity,
To the best of our knowledge, this is the first
PPV and NPV, and AUROC. In our population,
study to measure the validity of the TMD Pain
the TMD Pain Screener showed high sensitivity
Screener (alone and in combination with
but low specificity. This means that the TMD
predictors known to be associated with higher
Pain Screener tends to mistakenly identify
TMD prevalence) in endodontic patients
patients with only endodontic pain as having
presenting with a history of tooth pain. When
TMD pain. The low specificity is expected due
used by itself, the 3-question screener had low
to patients interpreting tooth pain as a form of
accuracy (AUROC 5 0.60), while the 6-
jaw pain, difficulty in distinguishing between
question version had useful accuracy
the 2 pain types, pain radiation and referral, as
(AUROC 5 0.71). Using the score of the full
well as some modifying factors for TMD pain
TMD Pain Screener in combination with the
overlapping with the modifying factors for tooth
numeric rating of patient’s current pain
pain.
intensity of their chief complaint improved
In clinical settings, PPV and NPV are
screening accuracy (AUROC 5 0.81), while
more relevant measures than sensitivity and
using additional TMD pain predictors did not
specificity. The 6-question version of the
result in any further improvement in the
screener had an NPV of 75%, indicating that if
screening accuracy (AUROC 5 0.81).
a patient screens negative, the endodontist
can confidently conclude that the patient does
not have painful TMD and proceed with NS-
RCT without further TMD examination. If a
patient screens positive, the screener’s PPV of
Scale* OR† 95% CL 68% suggests a two-thirds chance of the
SD 3.2 1.9, 5.4 patient having painful TMD, warranting a more
SD 2.3 1.5, 3.7 comprehensive TMD examination.
SD 2.4 1.5, 3.8 The original study validated the TMD
SD 2.4 1.5, 3.8 Pain Screener in a convenience sample of
SD 2.3 1.1, 4.5
research volunteers with nonpainful TMD,
SD 2.0 1.2, 3.4
SD 1.8 1.2, 2.7 painful TMD, or headache vs people without
binary 5.2 2.1, 12.9 painful TMD11. The full TMD Pain Screener was
shown to have very high sensitivity and
specificity (99% and 97%, respectively) in that
sample. However, the study excluded patients
with odontogenic pain from the analysis, which
explains why the screener performed much
better in their population.

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 Another study reported 92% sensitivity

Pain frequency in the

and 59% specificity of the full TMD Pain

last 30 days
Screener but investigated its performance in

0.307†
patients with exclusively endodontic pain and
patients with exclusively TMD pain15. In
addition, the study did not use the gold
standard DC/TMD exam in endodontic group
and excluded patients with mixed (both
endodontic and TMD) pain etiology. Our
sample consisted of consecutive patients with
tooth pain treated at university endodontic

0.215‡
PHQ-4

20.019
clinics and represented all the complexity of
patients seen in a typical endodontic practice.
Despite the greater symptom overlap and a
diagnostic challenge in our sample, which
included 46% of patients with dual pain
pain onset
Time from

0.204‡ etiology, the sensitivity and specificity of the full

0.033
0.007
TMD Pain Screener in our study (85% and
52%, respectively) were only slightly lower than
those in the Fonseca Alonso et al.
The AUROC of the 6- and 3-question
TMD Pain Screener in our population was 0.71
Pain to tooth

and 0.60 respectively, with only the full version

percussion

being classified as having “useful” or “good”

0.375*
0.580*
0.051
0.097

accuracy19,20. Assessing the combination of the

screener score and the patient’s rating of the
current pain intensity of the chief complaint
improved the AUROC to “very good” (0.81) and
“good” (0.77) overall accuracy, respectively.
Current pain

When more TMD predictors were added to the

intensity

0.301‡
0.423*

0.433*

full and short versions of the screener, the

0.085
0.182

AUROC showed little-to-no further

improvement (0.81 and 0.80, respectively).
Hence, we recommend the use of the 6-
question TMD Pain Screener in combination
with the current pain intensity rating of the chief
TMD screener
TABLE 3 - Coefficients of Pearson Correlations Between the Putative Predictors of the TMD Status

complaint (Fig. 4) as the most accurate currently

3-Question

available TMD screening tool in endodontic

0.233‡
0.294‡
0.083
0.164
0.188

0.175

patients with history of tooth pain.

The strengths of our study are a cross-
sectional design, blinding of the primary
investigator to the screening result, TMD
assessment according to the validated DC/
PHQ-4, Patient Health Questionnaire-4; TMD, Temporomandibular disorders.

TMD diagnostic criteria used as the reference

TMD screener
6-Question

standard, and a comprehensive endodontic

0.274†

0.277†
0.265†
0.269†
0.894*

0.327*
0.178

evaluation. The risk of diagnostic bias from

conducting the DC/TMD examination by a
single investigator is low, as previous TMD
studies demonstrated high inter-examiner
reliability among multiple examiners22,23. The
enrolled participants were all consecutive
Pain frequency in the last 30 days

eligible patients with history of tooth pain,

3-question TMD Pain Screener

including men and women of various races,

ethnicities, and ages, seeking evaluation and
Symp. Apical Periodontitis

0.001 P , .01 level (2-tailed).

Pain to tooth percussion

0.01 P , .05 level (2-tailed).

treatment in 3 endodontic specialty clinics.

Time from pain onset
Current pain intensity

The limitation of our study is that almost

*P , .001 level (2-tailed).

half of the prescreened patients were not

eligible or declined participation. Thus, the
Predictors

enrolled sample could differ from the original

PHQ-4

patient population. However, when compared

to a nation-wide study of patients seeking
endodontic treatment in a private dental
†

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TABLE 4 - Cross-Validated Multivariable Logistic Regression Models Evaluating Association Between the Putative Predictors and TMD Status

Model 2: Model 3:
Screener 1 pain Screener 1 all
Model 1: Screener intensity† univariate predictors
6-Question TMD pain screener
Predictor variable Scale OR (95% CL) OR (95%CL) OR (95%CL)
6-question TMD Pain Screener SD 3.2 (1.9, 5.4) 3.2 (1.9, 5.6) 2.5 (1.4, 4.6)
Current pain intensity* SD 2.4 (1.4, 3.9) 1.9 (1.0, 3.5)
Pain to tooth percussion SD 1.4 (0.7, 2.6)
Time from pain onset SD 1.9 (0.9, 4.4)
PHQ-4 SD 1.3 (0.7, 2.6)
Pain frequency in 30 days SD 1.1 (0.6, 2.0)
Sympt. Apical Periodontitis binary 2.5 (0.7, 8.9)
Model AIC 116.4 106.3 106.0
AUROC (95% CL) 0.71 (0.61, 0.82) 0.81 (0.72, 0.89) 0.81 (0.72, 0.89)
AUROC contrast P-values
compared to Model 1 0.006 0.034
compared to Model 2 0.895

Predictor variable Scale 3-question TMD Pain Screener

OR (95% CL) OR (95%CL) OR (95%CL)
3-question TMD Pain Screener SD 2.3 (1.5, 3.7) 2.5 (1.5, 4.1) 2.1 (1.2, 3.8)
Current pain intensity* SD 2.5 (1.5, 4.1) 2.0 (1.1, 3.7)
Pain to tooth percussion SD 1.5 (0.9, 2.8)
Time from pain onset SD 2.0 (1.0, 4.4)
PHQ-4 SD 1.3 (0.7, 2.7)
Pain frequency in 30 days SD 1.0 (0.5, 1.8)
Sympt. Apical Periodontitis binary 2.8 (0.8, 10.0)
Model AIC 127.0 113.8 109.1
AUROC (95% CL) 0.60 (0.48, 0.71) 0.77 (0.67, 0.86) 0.80 (0.71, 0.88)
AUROC contrast P-values
compared to Model 1 ,0.001 ,0.001
compared to Model 2 0.330

95% CL, 95% Confidence Limits; AIC, Akaike’s information criterion; AUROC, Area under the Receiver Operator Curve; PHQ-4, Patient Health Questionnaire-4; OR, Odds Ratio; SD,
standard deviation; TMD, Temporomandibular disorders.
P values , .05 are highlighted in a bold font.
*Current pain intensity of the chief complaint when presenting for the study visit.

practice, almost all patient characteristics in
our sample were consistent with their data24.
CONCLUSION
Given the high prevalence of painful TMD
among endodontic patients with history of
tooth pain, either as a co-morbid pain, a
component of the presenting pain, or a
single etiology of pain, it is imperative to
screen such patients for painful TMD with
valid screening tools. The 6-question TMD
Pain Screener combined with patient’s
rating of current pain intensity yielded useful
overall accuracy in detecting painful TMD in
this patient population. In endodontic
offices, this tool can be used to identify
patients who require further clinical
evaluation for TMD and to guide a
differential diagnosis between odontogenic
and TMD pain.

TMD Pain Numeric rating of current pain intensity of the chief complaint
Screener 0* 1 2 3 4 5 6 7 8 9 10
score
0
1
2
3
4
5
6
7

FIGURE 4 – TMD prediction by combinations of thresholds for the 6-question TMD Pain Screener and the current pain intensity of the chief complaint. Blue boxes are predicted non-
TMD cases and red boxes are predicted TMD cases at the optimal Youden’s index
0.5 (prediction accuracy of Se 1 Sp
1.50). Se, sensitivity; Sp, specificity; TMD, Tempo-
romandibular disorders. *Some patients were not experiencing pain at the moment of the visit, even though they have had pain in the preceding 30 days, and therefore “0” current pain
rating is included in the grid.

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CREDIT AUTHORSHIP
CONTRIBUTION STATEMENT
Iryna H. Daline: Conceptualization,
Methodology, Investigation, Writing – original
draft, Writing – review & editing, Funding
acquisition. Gary D. Slade:
Conceptualization, Methodology, Formal
analysis, Data curation, Writing – original draft,
Writing – review & editing. Ashraf F. Fouad:
Conceptualization, Methodology, Writing –
review & editing. Donald R. Nixdorf:
Conceptualization, Methodology, Writing –
review & editing. Inna E. Tchivileva:
Conceptualization, Methodology, Validation,
Resources, Writing – original draft, Writing –
review & editing, Project administration,
Supervision, Funding acquisition.
ACKNOWLEDGMENTS
This project ID#925075 was supported by
research grants from the American
Association of Endodontists Foundation, the
International Association for Dental
Research, the American Academy of
Orofacial Pain, and the Dental Foundation
of North Carolina.
Conflict of Interest: The authors deny
any conflicts of interest.
SUPPLEMENTARY MATERIAL
Supplementary material associated with this
article can be found in the online version at
www.jendodon.com (https://doi.org/10.1016/
j.joen.2023.10.011).

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