The new DC/TMD (Diagnostic Criteria for Temperomandibular Disorders). What does this mean for the specialized physical therapist?
Physiotherapists and dentist do have their own methods of assessing patients with orofacial problems. To become a better agreement in diagnosing orofacial complains within different kind of professions an international standard was made in 1992 (*1). This was called the Research Diagnostic Criteria for Temperomandibular Disorders (RDC/TMD).
This RDC/TMD has two assessment points of attention. In Axis 1 they describe the physical examination and Axis 2 helps with defining the biopsychosocial factors. Unfortunately for Axis 1 the validity wasn’t good enough. This meant that the possibility to recognise someone with orofacial complaints was only 70%. For Axis 2 this validity was somewhat better, however the existing tests where not always easy to work with and took a lot of time. Based on this knowledge there was decided to make an update of this protocol which was published in an article of Schiffman et al in 2014 (*2). The new revised and slightly changed protocol is now called DC/TMD
What is new?
In the new DC/TMD the examination protocol of Axis 1 exists of the following tests. During the assessment the examiner looks at the mouth opening and also at the movements to the side and to the front. A palpation of the joint can be done whereby there’s also attention for possible noises in the jaw region. In addition a palpation of the chewing muscles can be applied.
For Axis 2 the use of several questionnaires is described. They make a discrimination in simple screening tests which can be used in daily practise and some extended tests which will probably be used in a clinic setting. For the physiotherapist are 5 screenings-tests of importance. Those are the Patient Health Questionnaire-4 (PHQ-4), the Graded Chronic Pain Scale (GCPS), the Pain drawing of the head/jaw/body, the Jaw Functional Limitation Scale (JFLS) and the Oral Behaviours Checklist (OBC).
This examination protocol leads to new criteria for twelve common orofacial diagnoses in this DC/TMD. The new DC/TMD has a classification of complaints in the jaw region caused by muscles, joints, disk and subluxation or an headache related to this region. The differences with the old one are the addition of headache related to the TMJ-region, the disc displacement with reduction, the intermittent limited mouth opening and the subluxation (for an overview see the article of Schiffman *2)
The new DC/TMD provides us a valid tool which can be used by different professions. For Axis 1 its validity has improved (Sensitivity > 0,86, Specifity > 0,98). Axis 2 is easier to comply with a smaller time investment than the original one because of the adjustment of 5 simple screening-tests.
For the CRAFTA®-therapist knowledge of this assessment tool is important. Not only to interpret the kind of orofacial pain you are dealing with in your own daily practise but also for the communication with other professions. Of course, all of this must be seen in the total concept of clinical reasoning. The multifactorial assessment will be more extensive than just the DC/TMD. The search for the reproduction of comparable signs and symptoms, the understanding of the contributing factors and the implementation from all of this into your management may lead to an adequate treatment. Interested in all about the DC/TMD? Read it on the internet (*3).
Miranda Hanskamp, PT, OMT, CRAFTA®
*1: The original article was published by Dworkin and LeResche in 1992 in The Journal of Craniomandibular Disorders, Facial & Oral Pain
*2: Schiffman et al. 2014. Diagnostic criteria for temperomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the international RDC/TMD Consortium Network and orofacial pain special interest group. J. Oral Facial Pain Headache 28, 1:6–27