Journal of Oral & Facial Pain and Headache, 01/2010

Aims: The purpose of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Validation Project was to assess the diagnostic validity of this examination protocol. The aim of this article is to provide an overview of the project's methodology, descriptive statistics, and data for the study participant sample. This article also details the development of reliable methods to establish the reference standards for assessing criterion validity of the Axis I RDC/TMD diagnoses. Methods: The Axis I reference standards were based on the consensus of two criterion examiners independently performing a comprehensive history, clinical examination, and evaluation of imaging. Intersite reliability was assessed annually for criterion examiners and radiologists. Criterion examination reliability was also assessed within study sites. Results: Study participant demographics were comparable to those of participants in previous studies using the RDC/TMD. Diagnostic agreement of the criterion examiners with each other and with the consensus-based reference standards was excellent with all kappas >= 0.81, except for osteoarthrosis (moderate agreement, k = 0.53). Intrasite criterion examiner agreement with reference standards was excellent (k >= 0.95). Intersite reliability of the radiologists for detecting computed tomography-disclosed osteoarthrosis and magnetic resonance imaging-disclosed disc displacement was good to excellent (k = 0.71 and 0.84, respectively). Conclusion: The Validation Project study population was appropriate for assessing the reliability and validity of the RDC/TMD Axis I and II. The reference standards used to assess the validity of Axis I TMD were based on reliable and clinically credible methods. Schlagwörter: diagnostic criteria, gold standard, reference standard, temporomandibular disorders, temporomandibular muscle and joint disorders, validity

Aims: The primary aim was to determine new estimates for the measurement reliability of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms. A second aim was to present data on the reliability of key clinical measures of the diagnostic algorithms. Methods: Kappa (k), computed by generalized estimate equation procedures, was selected as the primary estimate of interexaminer reliability. Intersite reliability of six examiners from three study sites was assessed annually over the 5-year period of the RDC/TMD Validation Project. Intrasite reliability was monitored throughout the validation study by comparing RDC/TMD data collections performed on the same day by the test examiner and a criterion examiner. Results: Intersite calibrations included a total of 180 subjects. Intersite reliability of RDC/TMD diagnoses was excellent (k > 0.75) when myofascial pain diagnoses (Ia or Ib) were grouped. Good reliability was observed for discrete myofascial pain diagnoses Ia (k = 0.62) and Ib (k = 0.58), for disc displacement with reduction (k = 0.63), disc displacement without reduction with limited opening (k = 0.62), arthralgia (k = 0.55), and when joint pain (IIIa or IIIb) was grouped (k = 0.59). Reliability of less frequently observed diagnoses such as disc displacements without reduction without limited opening, and osteoarthrosis (IIIb, IIIc), was poor to marginally fair (k = 0.31-0.43). Intrasite monitoring results (n = 705) approximated intersite reliability estimates. The greatest difference in paired estimates was 0.18 (IIc). Conclusion: Reliability of the RDC/TMD protocol was good to excellent for myofascial pain, arthralgia, disc displacement with reduction, and disc displacement without reduction with limited opening. Reliability was poor to marginally fair for disc displacement without reduction without limited opening and osteoarthrosis. Schlagwörter: diagnostic criteria, reliability, temporomandibular joint disorders, temporomandibular muscle and joint disorders

Aims: To estimate the criterion validity of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I TMD diagnoses. Methods: A combined total of 614 TMD community and clinic cases and 91 controls were examined at three study sites. RDC/TMD Axis I diagnoses were algorithmically derived from an examination performed by calibrated dental hygienists. Reference standards ("gold standards") were established by means of consensus diagnoses rendered by two TMD experts using all available clinical data, including imaging findings. Validity of the RDC/TMD Axis I TMD diagnoses was estimated relative to the reference-standard diagnoses (gold standard diagnoses). Target sensitivity and specificity were set a priori at >= 0.70 and >= 0.95, respectively. Results: Target sensitivity and specificity were not observed for any of the eight RDC/TMD diagnoses. The highest validity was achieved for Group Ia myofascial pain (sensitivity 0.65, specificity 0.92) and Group Ib myofascial pain with limited opening (sensitivity 0.79, specificity 0.92). Target sensitivity and specificity were observed only when both Group I diagnoses were combined (0.87 and 0.98, respectively). For Group II (disc displacements) and Group III (arthralgia, arthritis, arthrosis) diagnoses, all estimates for sensitivity were below target (0.03 to 0.53), and specificity ranged from below to on target (0.86 to 0.99). Conclusion: The RDC/TMD Axis I TMD diagnoses did not reach the targets set at sensitivity of >= 0.70 and specificity of >= 0.95. Target validity was obtained only for myofascial pain without differentiation between normal and limited opening. Revision of the current Axis I TMD diagnostic algorithms is warranted to improve their validity. Schlagwörter: diagnostic criteria, gold standard, reference standard, temporomandibular disorders, temporomandibular muscle and joint disorders, validity

Aims: To evaluate the psychometric properties of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) biobehavioral (Axis II) screening instruments. Methods: Participants with Axis I TMD diagnoses (n = 626) completed the Axis II instruments (Depression, Nonspecific Physical Symptoms, Graded Chronic Pain) and other instruments assessing psychological distress, pain, and disability at three study sites. Internal consistency, temporal stability, and convergent/discriminant validity of the Axis II measures were assessed. To assess criterion validity of Nonspecific Physical Symptoms and Depression instruments as screeners, 170 participants completed a structured psychiatric diagnostic interview. Results: The Axis II instruments showed very good to excellent internal consistency (Cronbach's alpha coefficients = 0.80 to 0.95). Their convergent (correlation range 0.3 to 0.9) and discriminant (range 0.0 to 0.6) validity were generally supported, although Nonspecific Physical Symptoms was more strongly associated with depressive than with somatic symptoms. Temporal stability was high for characteristic pain intensity (Lin's correlation concordance coefficient [CCC] = 0.91), interference (CCC = 0.89), and chronic pain grade (weighted kappa = 0.87), and fair to good for Depression and Nonspecific Physical Symptoms (CCC = 0.63 to 0.78). The Depression instrument normal versus moderate to severe cutoff point was good at identifying current-year depression and dysthymia diagnoses (sensitivity 87%, specificity 53%). Nonspecific Physical Symptoms did not have high utility for detecting psychiatric disorders (sensitivity 86%, specificity 31%). Conclusion: The Axis-II Depression and Graded Chronic Pain instruments have clinically relevant and acceptable psychometric properties for reliability and validity and utility as instruments for identifying TMD patients with high levels of distress, pain, and disability that can interfere with treatment response and course of Axis I disorders. Schlagwörter: biobehavioral, RDC/TMD, screening, sensitivity, specificity

Aims: To derive reliable and valid revised Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms for clinical TMD diagnoses. Methods: The multisite RDC/TMD Validation Project's dataset (614 TMD community and clinic cases, and 91 controls) was used to derive revised algorithms for Axis I TMD diagnoses. Validity of diagnostic algorithms was assessed relative to reference standards, the latter based on consensus diagnoses rendered by two TMD experts using criterion examination data, including temporomandibular joint imaging. Cutoff points for target validity were sensitivity >= 0.70 and specificity >= 0.95. Reliability of revised algorithms was assessed in 27 study participants. Results: Revised algorithm sensitivity and specificity exceeded the target levels for myofascial pain (0.82, 0.99, respectively) and myofascial pain with limited opening (0.93, 0.97). Combining diagnoses for any myofascial pain showed sensitivity of 0.91 and specificity of 1.00. For joint pain, target sensitivity and specificity were observed (0.92, 0.96) when arthralgia and osteoarthritis were combined as "any joint pain." Disc displacement without reduction with limited opening demonstrated target sensitivity and specificity (0.80, 0.97). For the other disc displacement diagnoses, osteoarthritis and osteoarthrosis, sensitivity was below target (0.35 to 0.53), and specificity ranged from 0.80 to meeting target. Kappa for revised algorithm diagnostic reliability was >= 0.63. Conclusion: Revised RDC/TMD Axis I TMD diagnostic algorithms are recommended for myofascial pain and joint pain as reliable and valid. However, revised clinical criteria alone, without recourse to imaging, are inadequate for valid diagnosis of two of the three disc displacements as well as osteoarthritis and osteoarthrosis. Schlagwörter: reference standard, reliability, research diagnostic criteria, temporomandibular disorders, temporomandibular muscle and joint disorders, validity

The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Validation Project has provided the first comprehensive assessment of reliability and validity of the original Axis I and II. In addition, Axis I of the RDC/TMD was revised with estimates of reliability and validity. These findings are reported in the five preceding articles in this series. The aim of this article is to present further revisions of Axis I and II for consideration by the TMD research and clinical communities. Potential Axis I revisions include addressing concerns with orofacial pain differential diagnosis and changes in nomenclature in an attempt to provide improved consistency with other musculoskeletal diagnostic systems. In addition, expansion of the RDC/TMD to include the less common TMD conditions and disorders would make it more comprehensive and clinically useful. The original standards for diagnostic sensitivity (= 0.70) and specificity (= 0.95) should be reconsidered to reflect changes in the field since the RDC/TMD was published in 1992. Pertaining to Axis II, current recommendations for all chronic pain conditions include standardized instruments and expansion of the domains assessed. In addition, there is need for improved clinical efficiency of Axis II instruments and for exploring methods to better integrate Axis I and II in clinical settings. Schlagwörter: clinical utility, diagnostic criteria, nomenclature, research, temporomandibular disorders

Aims: To develop and test a biopsychosocial model using structural equation modeling for predicting orofacial pain symptoms in a sample of patients with masticatory muscle pain (MMP). Methods: Data were collected from clinic records of 251 adult patients who presented for initial evaluation to the Orofacial Pain Center at the University of Kentucky College of Dentistry and were subsequently diagnosed with MMP. Data were used to fit a model relating stressors, psychological distress, arousal, sleep problems, oral parafunction, and pain symptoms. Items from the Multidimensional Pain Inventory (MPI) and the IMPATH:TMJ, a comprehensive biopsychosocial assessment of patients with temporomandibular disorders (TMD), were used to construct a measurement model of five latent variables. Results: Estimation of the model indicated a good fit to the data and significant associations between stressors, psychological distress, arousal, sleep problems, and pain symptoms. Sleep problems partially mediated the relation between arousal and pain symptoms. Contrary to hypotheses, no association occurred between oral parafunction and pain symptoms, possibly indicating that any relationship between oral parafunction and pain symptoms may not exist. Conclusion: Results from the model tested in the present study are an additional step toward developing a more comprehensive biopsychosocial model explaining the nature and etiology of MMP in orofacial pain and TMD. With additional development and testing, it may also serve as an aid to planning interventions, especially psychosocial interventions targeting stress management, psychophysiological regulation, psychological distress, and sleep problems. Schlagwörter: biopsychosocial factors, chronic orofacial pain, masticatory muscle pain, structural equation model, temporomandibular disorders

Aims: To evaluate the choice of activities on the Patient Specific Approach (PSA) in a sample of temporomandibular disorder (TMD) patients and to determine the clinimetric properties of the visual analog scale (VAS) scores of the PSA, in terms of reproducibility and responsiveness. Methods: At treatment start, TMD patients reported the PSA activity which represents the most important activity that is impaired due to their TMD complaints. The amount of hindrance during this activity was rated on a VAS. During two follow-up measurements, patients used the VAS to rate the amount of hindrance and appraised their overall complaints in terms of "much worsened," "slightly worsened," "remained stable," "slightly improved," or "much improved." To determine the reproducibility and responsiveness, an intraclass correlation coefficient and receiver operating characteristics-curve were then calculated. Results: Of the 132 patients who fulfilled baseline measurements, 13% reported an activity that is not included in existing TMD-disability questionnaires. The reproducibility of the VAS scores of the 78 patients who reported that their complaints had "remained stable" at second measurement was good (intraclass correlation coefficient = 0.73). The responsiveness of the PSA was high, and the cutoff score for important improvement, where sensitivity (0.85) and specificity (0.84) were as much as possible the same, was 58%. Conclusion: The PSA for TMD patients is a new and easy-to-use tool in treatment evaluation. Moreover, the VAS score of the PSA has good reproducibility and responsiveness. Schlagwörter: patient specific approach, reproducibility, responsiveness, TMD, treatment effect

Aims: To investigate the effects of dry needling over active trigger points (TrPs) in the masseter muscle in patients with temporomandibular disorders (TMD). Methods: Twelve females, aged 20 to 41 years old (mean = 25, standard deviation ± 6 years) diagnosed with myofascial TMD were recruited. Each patient attended two treatment sessions on two separate days and received one intervention assigned in a random fashion, at each visit: deep dry needling (experimental) or sham dry needling (placebo) at the most painful point on the masseter muscle TrP. Pressure pain threshold (PPT) over the masseter muscle TrP and the mandibular condyle and pain-free active jaw opening were assessed pre- and 5 minutes postintervention by an examiner blinded to the treatment allocation of the subject. A two-way repeated-measures analysis of variance (ANOVA) with intervention as the between-subjects variable and time as the within-subjects variable was used to examine the effects of the intervention. Results: The ANOVA detected a significant interaction between intervention and time for PPT levels in the masseter muscle (F = 62.5; P .001) and condyle (F = 50.4; P .001), and pain-free active mouth opening (F = 34.9; P .001). Subjects showed greater improvements in all the outcomes when receiving the deep dry needling compared to the sham dry needling (P .001). Conclusion: The application of dry needling into active TrPs in the masseter muscle induced significant increases in PPT levels and maximal jaw opening when compared to the sham dry needling in patients with myofascial TMD. Schlagwörter: dry needling, masseter, temporomandibular disorder, trigger points

Aims: To investigate the effects of morphine on mechanical allodynia following compression of the trigeminal ganglion in the rat. Methods: Experiments were carried out on male Sprague-Dawley rats weighing between 250 and 260 g. For compression, a 4% agar solution (8 µL) was injected into the trigeminal ganglion. In the control group, rats were sham operated without agar injections. The authors evaluated the effects of intraperitoneal or intracisternal administration of morphine on mechanical allodynia evoked by air-puff stimulation of the vibrissa pad area 14 days following compression of the trigeminal ganglion. Results: Mechanical allodynia was established within 3 days and lasted beyond postoperative day 24. Intraperitoneal administration of morphine (2 or 5 mg/kg) significantly blocked mechanical allodynia ipsilateral to the compression of the trigeminal ganglion. Intraperitoneal administration of morphine also inhibited mechanical allodynia on the contralateral side. Moreover, intracisternal administration of morphine (5 µg) strongly suppressed both ipsilateral and contralateral mechanical allodynia. The antiallodynic effects of morphine were blocked by pretreatment with naloxone, an opioid receptor antagonist. Conclusion: These results suggest that the application of a high dose of morphine may be of great benefit in treating trigeminal neuralgia-like nociception. Schlagwörter: allodynia, animal model, morphine, trigeminal ganglion, trigeminal neuralgia