journal of dentistry 37 (2009) 955962

available at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/jden

Adapting the diagnostic definitions of the RDC/TMD

to routine clinical practice: A feasibility study
Fatin Hasanain a, Justin Durham b, Adel Moufti a, Ian Nick Steen c, Robert W. Wassell d,*
a

Department of Restorative Dentistry, United Kingdom

Department of Oral and Maxillofacial Surgery, United Kingdom
c
Institute of Health & Society, United Kingdom
d
Department of Restorative Dentistry, The School of Dental Sciences, Framlington Place, Newcastle upon Tyne, NE2 4BW, United Kingdom
b

article info

abstract

Article history:

The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) is a well-

Received 12 December 2008

known diagnostic tool for clinical trials on TMD.

Received in revised form

Objectives: This study aims to assess the reliability, validity and feasibility of a new method

3 August 2009

of physically diagnosing temporomandibular disorders (TMD), designed for routine clinical

Accepted 5 August 2009

use. This version, known as Clinical Examination Protocol-TMD (CEP-TMD), was compared
to the gold standard original RDC/TMD.
Methods: A total of 49 subjects (41 referred TMD patients and 8 symptom free subjects) were

Keywords:

examined using both RDC/TMD and CEP-TMD versions. Three examiners, with varying

RDC/TMD

levels of experience in diagnosing TMD, worked in pairs. Each member of a pair saw the

Reliability

same patient twice, once for the RDC/TMD and once for the CEP-TMD examination. The

CEP-TMD

examination order was randomized. Each patients examinations alternated between

Physical TMD diagnosis

examiners to reduce the memory effect. Examinations could yield single, multiple or no

Clinical tool

diagnosis. Kappa statistics were calculated to estimate reliability.

Results: There was substantial overall agreement between the CEP-TMD and the RDC/TMD
(kappa = 0.70). Intra-examination agreements were substantial in both RDC/TMD
(kappa = 0.70) and CEP-TMD (kappa = 0.90). For examination and diagnosis, the CEP-TMD
was almost 3 min faster than the RDC/TMD ( p < 0.05).
Conclusions: It was concluded that the CEP-TMDs diagnosis is comparable to the RDC/TMD
thus providing a convenient and intuitive approach for dentists to physically diagnose TMD
in clinical practice. The well-established RDC/TMD remains the gold standard for research
diagnosis of TMD.
# 2009 Elsevier Ltd. All rights reserved.

1.

Introduction

Diagnosing temporomandibular disorders (TMD) has been a

subject of much research for the past three decades. Since its
introduction in 1992, the Research Diagnostic Criteria for TMD
(RDC/TMD) has gained wide acceptance as a diagnostic
classification tool and its validity has been tested several

times,14 so much so that it is now considered a gold standard

by much of the dental research community. It has truly
operationalized TMD examination and diagnoses by providing
detailed instructions as well as diagnostic algorithms.
Despite the existence of these diagnostic criteria, many
general dental practitioners tend to look upon TMD diagnosis
and management with a large degree of confusion and

* Corresponding author. Tel.: +44 0191 2226000; fax: +44 0191 2226137.
E-mail address: R.W.Wassell@ncl.ac.uk (R.W. Wassell).
0300-5712/$ see front matter # 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2009.08.001

956

journal of dentistry 37 (2009) 955962

Fig. 1 Diagnostic criteria for the CEP-TMD derived from the RDC/TMD.

ambiguity. Tegelberg et al.5 found that many dentists lacked

routines for making diagnoses and only 2550% of dentists
reported positive experiences in relation to TMD diagnosis and
management. Another study found that general dental practitioners expressed a fear of misdiagnosing TMD and often
referred these patients to specialist centres or hospital settings.6
The systematic approach of the RDC/TMD has the potential
to help dentists overcome these problems, but so far the RDC/
TMD appears to be used rarely in routine clinical practice.
A team of researchers at Newcastle created a new
diagnostic protocol for TMD7 which has been in clinical use
for over 5 years; this is referred to as the clinical examination
protocol-TMD (CEP-TMD). To simplify diagnosis of TMD in the

routine clinical setting, the CEP-TMD provides a list of the

main criteria for each diagnostic group and subgroup derived
from the RDC/TMD1 (Fig. 1). As the examination proceeds and
the criteria are met, a diagnosis can be made, which has the
potential to reduce the time needed with the RDC/TMD
algorithms after the examination.1
Both examinations can be seen as online videos at http://
www.rdc-tmdinternational.org/ and http://www.ncl.ac.uk/
dental/AppliedOcclusion/ (both last accessed 31.07.09). These
sites also provide history and examination forms.
The purpose of this study is to examine the feasibility of
using the CEP-TMD as a valid and reliable means of diagnosing
TMD in the routine clinical setting. The two aims are to:

journal of dentistry 37 (2009) 955962

(1) compare the diagnoses obtained by using the CEP-TMD to

those made using RDC/TMD.
(2) determine the average time required to complete the
diagnosis for each system.

2.

Materials and methods

2.1.

Subjects

Two groups of subjects were used in this study; TMD patients

and symptom free subjects. Putative TMD patients were
identified from their general dental practitioners letter of
referral to Newcastle Dental Hospital. The term TMD patient
was used for this group even though a hospital TMD diagnosis
had yet to be made. To be included they needed to be 18 years
of age or over and the letter needed to describe a TMD related
complaint or a provisional diagnosis of TMD. They were
excluded if at any point it was found that: their pain did not
originate from TMD; they were in acute pain; they were
undergoing orthodontic treatment as this can produce
transient TMD symptoms; they had one or two edentulous
arches; or they had been previously treated for TMD.
A member of the team contacted potential patients by
telephone after they had been sent a letter explaining the
nature of the trial and invited them to be included in the study.
Those who agreed to be involved were offered an appointment
solely to have their TMD diagnosis made. They were then seen
24 weeks later for routine management on a consultant
clinic.
Symptom free subjects were volunteers selected by the
nurse working with the research team to avoid biasing the
clinicians. The inclusion criteria were that the subjects were
over 18 years of age and did had not have a facial ache or pain
in the jaw muscles, the joint in front of the ear, or inside the ear
(other than infection) for the past 6 months.8 The same
exclusion criteria applied for them as for the symptomatic
subjects.
The RDC/TMD website recommends 24 subjects for a
reliability study (1820 TMD patients and 46 asymptomatic
subjects). As this study compared two types of examinations,
the recommended sample size was doubled and then checked
to see that it would enable the estimation of sensitivity and
specificity with a reasonable amount of precision. It was
determined that with 48 patients, the standard of error would
be 4.33% assuming 90% confidence. Accordingly, 60 subjects
were booked for the research clinics, but due to 8 subject
withdrawals and 3 exclusions (one complete denture wearer
and two patients in severe pain at time of presentation) this
reduced to 49; 41 of which were putative TMD patients and 8
were non-symptomatic subjects.
This project gained ethical approval in October, 2006 from
the Newcastle and North Tyneside Local Research Ethics
Committee (ref: 06/Q0905/120).

2.2.

Procedure

The research team consisted of 3 clinicians:

 a restorative consultant with extensive experience diagnosing and treating TMD (Examiner 1)

957

 a clinical fellow/honorary specialist registrar with seven

years of experience of diagnosis of TMD and its conservative, holistic and surgical management (Examiner 2)
 a clinician who had 5 years of experience as a general dental
practitioner (Examiner 3).
The three clinicians training began with the RDC/TMD
online teaching video (produced by the Dept of Oral Medicine
of the University of Washington at http://www.RDC/TMDtmdinternational.org/). Electronic scales were used to train the
team in applying appropriate palpation force (1 Kg extra orally
and 500 g intra orally). The team was then calibrated in using
the RDC/TMD examination form. Following the examination
of three TMD patients by all three clinicians the results were
discussed and any minor differences ratified.
After calibration, the examiners were divided into three
pairs for the clinical study. Pair A (examiners 1 and 2), pair B
(examiners 2 and 3), and pair C examiners (1 and 3). Each pair
of examiners examined subjects using both the CEP-TMD and
RDC/TMD Axis I examination forms.1 That meant each subject
would receive a total of 4 examinations, two by each examiner.
The order of examination was randomly assigned.
Subjects were seen in two groups of three per research
session to allow each clinician to be the first to see a patient,
thus balancing the order effect. For the RDC/TMD examination
the multi page examination form was used. For the CEP-TMD a
single page examination form was used based on that of the
Temporomandibular Index TMI.9 The TMJ and muscle palpation sites were the same as for the RDC/TMD but with minor
modifications made to the protocol. These are:
(1) The TMJs and extra-oral muscles are palpated bilaterally
rather than unilaterally.
(2) The neck muscles are included, although they are not
directly involved in the TMD diagnosis.
(3) The order of examination (Table 1) was changed to make it
more intuitive for clinicians.
Each patient was examined in private by one examiner at a
time using the examination sequence outlined in Table 1 (for
further details please access the online video mentioned in
Section 1). This prevented any influence on the outcome of
the next examination, which was carried out by the second
member of the pair while the first member examined another
patient. In this way, the memory of the first examination was
reduced. Examiners made the CEP-TMD diagnosis as the
examination proceeded by matching the criteria to the
clinical findings in respect of the TMJs, muscles of mastication and jaw movement. Examiner 3 made all the RDC/TMD
diagnoses using the appropriate algorithms1 after the clinic
had finished.
After the last exam, a dental examination was performed
to ensure there was no dental cause for a subjects symptoms.
In addition, the history was then reviewed. This information
had been gathered using a Performa in the waiting room and
had been kept away from examiners by the nurse leading the
clinic until that point. A diagnosis was given to the patient
based on this information plus the CEP-TMD diagnosis.
Patients then received initial counselling using the host
institutes TMD counselling sheet which details exacerbating

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journal of dentistry 37 (2009) 955962

Table 1 Summary of RDC/TMD and CEP-TMD showing differences in examination order and palpation.
RDC/TMD
Order of examination

a
b
c

CEP-TMD

1.Deviation and pattern of opening

2.Vertical range of motion
3.Digital palpation of:
a. Joint sounds on opening and closinga
b. Muscle and joint pain on excursive movementsa
c. Joint sounds on excursive movementsa
d. Extra-oral musclesb
e. Joint painb
f. Intra oral musclesb

1. Joint examination
Pain evoked by digital palpation of TMJa and wide opening
Joint sounds on opening, closing and excursionsa
2. Muscle examination: digital palpation of
a. Neck and shoulder musclesc
b.Extra-oral muscles of masticationa
c. Intraoral musclesb
3. Functional examination:
Deviation and pattern of opening
Vertical range of motion

Bilateral palpation.
Unilateral palpation.
The results of the bilateral neck muscle palpation do not influence the TMD diagnosis.

factors as well as self management techniques including

habit modification, exercises, diet modification and analgesia. The diagnosis and any other relevant observations were
forwarded with their referral letter to the consultant clinics in
the Dental Hospital. At follow-up their conditions were then
re-assessed and management continued on a case-by-case
basis.

2.3.

Statistical analysis

This study evaluated a new diagnostic tool (CEP-TMD) against

a gold standard (RDC/TMD). With both tools, each subject was
assigned to zero, one or multiple diagnostic categories. These
were treated as independent observations and individually
coded to allow statistical analysis. The gold standard was
then used to determine the proportion of asymptomatic
subjects and patients correctly identified using the CEP-TMD
system. With 49 subjects the standard error of the estimate
was 3.5%.
Comparisons between the CEP-TMD and the RDC/TMD
were made using Cohens kappa10 for each individual
examiner and between examiners in each of the 3 pairings.
To provide an overall comparison (Cohens kappa) between
CEP-TMD and RDC/TMD all the examiners results were
combined. This process also allowed overall comparisons
between the diagnoses resulting from repeated examinations with each diagnostic system. Clearly, the greatest
statistical power would be with the overall comparison
between CEP-TMD and RDC/TMD as this would have twice
the number of observations as the RDC/TMD cf. RDC/TMD
and CEP-TMD cf. CEP-TMD comparisons. The kappa values
and confidence intervals were calculated by using a web
based
application
http://faculty.vassar.edu/lowry/kappa.html (last accessed 31.07.09). This application was
advised by our statistician as, unlike many proprietary
packages, it allowed multiple kappa comparisons between
groups of unequal size.
The value of kappa varies between 0 and 1; the higher the
kappa the better the agreement. It is generally agreed that a k
value of 0.20.4 signifies fair agreement, 0.410.60 is moderate,
0.610.80 is substantial, and 0.811 is almost perfect.11
The examination times were analyzed using Students t
test with the level of significance for a type 1 error set at
0.05.

3.

Results

The 41 TMD patients had a mean age of 44.2 years (SD = 13.8)
and a male: female ratio of 8:33. The 8 control subjects had a
mean age of 35.9 years (SD = 15.3) and a male: female ratio of
1:7. Neither of the examinations diagnosed any of the controls
as having a TMD. Therefore, all the results in Tables 27 relate
to the referred TMD patients.
For the 41 TMD patients examined in this study, 48
independent diagnoses were made using the RDC/TMD
examination and 50 were made using the CEP-TMD exam.
Table 2 shows their breakdown into the main RDC/TMD
diagnostic groups. In each pair, the more experienced
members diagnoses were used as the final diagnoses in cases
of a lack of agreement.
Table 3 illustrates the number of referred patients securing
zero, one or more diagnoses with either RDC/TMD or CEPTMD. Clearly, some patients did not obtain a TMD diagnosis; 8
for RDC/TMD and 6 for CEP-TMD.
Intra-examiner agreement for RDC/TMD versus CEP-TMD
was calculated for each of the 3 examiners. The kappa values
and percent agreements are shown in Table 4. Interexaminer
kappa agreements for each of the three examiner pairs ranged
from 0.6 to 0.67 for the RDC/TMD and from 0.82 to 0.85 for the
CEP-TMD.

3.1.
Overall agreement within and between diagnostic
systems
Table 5 provides kappa values and confidence intervals for the
comparison within diagnostic systems (RDC/TMD cf. RDC/
TMD, CEP-TMD cf. CEP-TMD) and between diagnostic systems
(RDC/TMD cf. CEP-TMD) for the TMD patients. Overall, the
RDC/TMD showed substantial agreement (kappa = 0.70, CI
0.560.84), while the CEP-TMD showed almost perfect agreement (kappa = 0.90, CI 0.810.99). The comparison between
CEP-TMD and RDC/TMD showed substantial agreement
(kappa = 0.70 CI 0.600.79). In addition, Table 5 provides kappa
values for the three main RDC/TMD diagnostic groups.
Agreements generally ranged between substantial and almost
perfect. However, fair to moderate agreements were seen with
Group I diagnoses when comparing the CEP-TMD with the
RDC/TMD and also with Group II diagnoses from the RDC/TMD
examination.

959

journal of dentistry 37 (2009) 955962

Table 2 Breakdown of main RDC/TMD diagnostic groups in both RDC/TMD and CEP-TMD Exams.
RDC/TMD

CEP-TMD

No. of diagnoses

% of total

No. of diagnoses

14
5

29
10

15
8

31
17

19

39

23

48

5
13
3
2
0
1

10
27
6
4
0
2

4
11
2
1
0
1

8
23
4
2
0
2

24

49

19

39

6
0
0
0
2
4

3
0
0
0
1
2

6
0
0
0
2
4

12

12

Group I (muscle disorders)

Ia
Ib
Total
Group II (disc displacement)
II a rt
II a left
II b rt
II b left
II c rt
II c left
Total

Group III (Arthralgia, osteoarthrosis and osteoarthritis)

III a rt
3
III a left
0
III b rt
0
III b left
0
III c rt
1
III c left
2
Total

Table 3 Frequency table of number of diagnoses per

patient in RDC/TMD and CEP-TMD.
RDC/TMD
No diagnosis
One diagnosis
Two diagnoses
Three diagnoses

CEP-TMD

8
21
8
4

7
22
9
3

Table 4 Intra-examiner testing comparing RDC/TMD

and CEP-TMD.
Examiner

Kappa

Examiner 1
Examiner 2
Examiner 3

0.71
0.69
0.69

3.2.

Percent agreement
76%
73%
74%

Examination times

Table 6 shows the difference between the time for examining

and diagnosing TMD in referred TMD patients using the CEPTMD and the RDC/TMD. The CEP-TMD was significantly faster
to perform than the RDC/TMD ( p < 0.05).

4.

Discussion

This study was undertaken to compare the reproducibility of a

more user friendly version of the RDC/TMD, i.e. the CEPTMD, within itself and against the RDC/TMD. The study was
principally designed to allow intra-examiner comparisons
between RDC/TMD and CEP-TMD, but as two examiners

% of total

examined each patient, it was also possible to provide interexaminer comparisons for each diagnostic system. Agreements within and between the individual examiners were
substantial, despite differing experience in managing TMD.
These findings justified the decision to make overall comparisons by amalgamating the examiners data.
The overall agreements within and between examination
systems ranged between substantial to near perfect and had
relatively narrow confidence intervals (see Table 5). The
overall agreement was substantial with a kappa of 0.70 in
both RDC/TMD versus RDC/TMD, and RDC/TMD versus CEPTMD. It is worth emphasizing that these agreements would
have been even better if the asymptomatic controls were
included because both examination systems correctly identified every subject as not having TMD. Interestingly, the intraexaminer agreement was higher for the CEP-TMD than that for
the RDC/TMD (0.9 c.f. 0.7). This could be because the
examiners were generally more familiar with the CEP-TMD,
with examiners 1 and 3 using it routinely in clinical hospital
practice.
When comparing the overall agreements for each of the
three main RDC/TMD diagnostic groups (Table 5), it is
important to bear in mind the wide confidence intervals for
the kappa values, which reflect the relatively small number of
observations for individual diagnoses. Nevertheless, the point
estimates of kappa showed agreement to be generally
substantial to near perfect, but with two exceptions where
agreement was less good: Group I diagnoses comparing CEPTMD with RDC/TMD, and Group II diagnoses using the RDC/
TMD examination.
The agreement for Group I diagnoses was substantial
within each diagnostic system, but became only fair to
moderate when comparing the CEP-TMD to the RDC/TMD.

960

journal of dentistry 37 (2009) 955962

Table 5 Agreement within and between diagnostic systems (cf. compared with).
RDC/TMD
diagnosis

RDC/TMD cf. RDC/TMD

Kappa

95% confidence interval

Lower limit

Upper limit

CEP-TMD cf. CEP-TMD

Kappa

95% confidence interval

Lower limit

Upper limit

RDC/TMD cf. CEP-TMD

Kappa

95% confidence interval

Lower limit

Upper limit

Group I
Group II
Group III

0.6
0.37
0.71

0.27
0.12
0.20

0.93
0.63
1

0.75
0.71
0.71

0.50
0.48
0.20

1
0.95
1

0.43
0.60
0.86

0.22
0.42
0.60

0.64
0.77
1

Overall

0.70

0.56

0.84

0.90

0.81

0.99

0.70

0.60

0.79

Table 6 Time taken to examine and diagnose TMD patients using RDC/TMD and CEP-TMD.
Examiner

RDC/TMD
mean time

CEP-TMD
mean time

p value

95% Confidence interval of

the difference
Lower

Upper

1
2
3

12.9
8.5
9.6

9.2
5.9
7.4

0.010
0.000
0.016

2.8
1.6
1.3

4.8
3.5
3.0

1+2+3

10.3

7.5

0.000

2.1

3.5

Other studies have reported Group I diagnoses to have

relatively low kappa scores in some clinical studies1214 but
good agreement in others2,15 suggesting muscle palpation
responses vary from day to day as well as from one exam to
another.13,16 In the same way, our findings may suggest
problems generally with the reliability of muscle palpation. It
may simply be, however, that each diagnostic system is
effective in diagnosing myofascial pain but one system
diagnoses more patients than the other. The number of Group
I diagnoses will ultimately depend on the number of muscle
palpation sites that are tender, which may in turn depend on
the mode of palpation. In this respect, Table 2 shows that the
CEP-TMD provided 4 more patients with Group I diagnoses
than did the RDC/TMD. Clearly, this difference in number of
diagnoses is likely to have been a major factor in reducing the
overall agreement when comparing diagnostic systems.
Further work is needed to determine whether any systematic
differences underlie the greater number of CEP-TMD Group I
diagnoses. Surprisingly, there are no previously published
comparisons of unilateral versus bilateral palpation of jaw
musculature. It should be remembered that the RDC/TMD
system specifies unilateral palpation, although bilateral
muscle palpation is the usual textbook teaching.
In relation to Group II diagnoses, the reliability of
diagnosing disc displacements with the RDC/TMD appears
generally somewhat variable. John and Zwijnenburg3 reported
agreements for Group IIa (disc displacement with reduction) to
vary between 0.33 and 0.71 and in another study reported a
median ICC of 0.61.17 On the other hand, Wahlund et al.2 noted
excellent reliability in Group II (kappa > 0.78). Such variability
reflects inconsistencies in the presentation of clicking and
locking. It also reflects the ability of the examiner to detect
them reliably which, as with other aspects of the examination,
may improve with training.16 Interestingly, the examiners in
the current study did rather better with the CEP-TMD
examination than with the RDC/TMD examination
(kappa = 0.71 c.f. 0.37). As with muscle palpation, however,

the method of palpation may influence results. The CEP-TMD

requires bimanual palpation from directly behind the patient,
whereas the RDC/TMD requires the examiner to sit to one side
in front of the patient. Such a posture results in asymmetrical
palpation, making it more difficult to standardize digital
location and pressure when assessing TMJ clicking. Again,
further work is needed to determine systematic differences
between palpation techniques. Such work would require
larger numbers of examiners and patients, no doubt benefiting
from a multicentre approach.
With the time taken for examination and diagnosis, overall
the CEP-TMD was almost 3 min faster than the RDC/TMD
( p < 0.05). This difference was significant for each of the three
examiners. With a simpler and shorter form to complete and
immediately available diagnoses this may make the CEP-TMD
more appropriate and attractive for day-to-day busy clinical
practice or for those who may have a limited knowledge of TMD
and need clear and concise direction in their diagnostic process.
Furthermore, the same form is a useful means for recording
clinical data at follow-up and the single sheet format makes it
simple to assess treatment outcome in terms of changes in joint
sounds, tenderness to palpation and jaw mobility.
The broad range of patients seen in this study was typical of
those referred to a dental hospital for management of TMD.
The TMD patients who did secure a diagnosis were distributed
between every RDC/TMD diagnostic group with the exception
of Group III b. The majority of the diagnoses were either RDC/
TMD Group I (39% using the RDC/TMD examination, 48% using
the CEP-TMD) or Group II (49% using the RDC/TMD examination and 39% using the CEP-TMD) making them the most
prevalent conditions in this study. The remaining 12% in both
examinations fell into RDC/TMD Group III, thus making it the
least prevalent set of conditions. John et al.17 found similar
prevalence.
Paradoxically, several patients failed to secure a diagnosis (8
using the RDC/TMD examination and 6 using the CEP-TMD with
5 of them not diagnosed by either examination) even though

journal of dentistry 37 (2009) 955962

they had a complaint in or around the TMJ and muscles of

mastication. The 5 patients not diagnosed by either examination had been referred for the following jaw problems:
 Loud, non painful click
 History of a click which disappeared, leaving mild discomfort
 History of dislocating jaw
 Transient pain in the jaw and neck area
 Bruxism during stress and jaw aches during those periods
of life.
The remaining patients scored a diagnosis with one exam
but not with the other. Two of them had 12 painful muscles
on palpation during the first two exams which increased to 45
by the time the second two exams were carried out. Both these
patients had the RDC/TMD carried out first. The other two
patients had a variable click during the first two examinations
that became more reproducible in the second two. One of the
patients had the RDC/TMD examination first but scored a
diagnosis in the CEP-TMD, while on the other had the CEPTMD carried out first and secured a diagnosis in the RDC/TMD.
These findings illustrate the potential difficulty of using a
research tool to make a working clinical diagnosis where the
signs and symptoms (e.g. those of dislocation) may not fit the
strict definitions of the RDC/TMD criteria or the CEP-TMD
definitions derived from them. Alternatively, an RDC/TMD
diagnosis may not be possible because symptoms are not
reproducible or transient.

4.1.

Strengths and limitations

To determine whether a high degree of expertise is needed to

carry out the RDC/TMD and CEP-TMD examinations this study
used three examiners with different backgrounds and
experience in diagnosing TMD. Each one of them had
examined sufficient patients in line with the RDC/TMD
recommendations. Fortunately, the each of the three examiners showed similar agreement between RDC/TMD and CEPTMD diagnoses, but had there been differences these could
have skewed the results. In view of the good inter-examiner
agreement all the examiners diagnoses were amalgamated,
allowing overall comparisons to be made within and between
RDC/TMD and CEP-TMD.
The number of examinations per patient was necessarily
limited. The ideal way of comparing the two examinations
would have been to examine each patient 8 times with each
examiner in a pair using both the RDC/TMD and CEP-TMD
twice. Even though that would ensure that intra- and interexaminer reliability could be calculated on the same patient, it
would have been ethically unacceptable as well as intolerable
to the patients. The statistical solution was to examine each
patient only 4 times and then amalgamate the diagnoses of all
three examiners which the authors acknowledge causes a
decrease in the sensitivity of the results.
A minor limitation of multiple examinations is that they
are inappropriate for patients in severe pain. Only two patients
were excluded for that reason.
The memory effect could have skewed the results had
examiners simply recalled aspects of their initial examination.

961

However, the imperfect intra-examiner agreement for detecting muscle tenderness and disc displacements showed this to
be unlikely.
It must be acknowledged that with two of the examiners
substantially more familiar with the CEP-TMD than the RDC/
TMD there is a potential for bias in favour of the CEP-TMD. It is
therefore recommended that the study is repeated in other
centres where neither the CEP-TMD nor preferably the RDCTMD is in general use.

4.2.

Clinical implications

Being able to diagnose TMD patients physical problems

effectively is helpful for dentists in deciding whether to treat
or to refer; it also helps standardize communication during
referral. More importantly, it would allow GDPs to allay
patients fears immediately rather than waiting for a
specialist or hospital based consultant to do so which
sometimes, due to waiting lists, takes some months.6,18,19 If
the dentist decides to treat the patient, the examination form
has the potential to provide a useful means of monitoring
changes at follow-up.
Should dentists use either the RDC/TMD or CEP-TMD
systems in clinical practice they need to recognize that the
RDC/TMD is principally designed to provide a physical
research diagnosis with a high level of sensitivity and
specificity. Clearly there will be those patients with genuine
sub-diagnostic level TMD symptoms not securing an RDC/
TMD diagnosis which in this study comprised 20%. Until
research proves the contrary it should not be assumed that
they have lesser associated problems, e.g. impact on quality of
life,17,19 than those that do secure such a diagnosis. Furthermore, a lack of an RDC/TMD diagnosis does not imply that
treatment be withheld. Finally, it should also be emphasized
that any diagnostic system used for TMD relies on clinicians
also making an appropriate evaluation of other causes of facial
and dental pain as well as confirming the presence or absence
of TMD. In particular, the use of static and dynamic tests may
sometimes be helpful to supplement muscle and TMJ
palpation in reaching an accurate diagnosis of TMD related
pain.20 Such tests have the capacity to provoke the patients
underlying pain if TMD related.

5.

Conclusion

In conclusion, the CEP-TMDs diagnosis is comparable to that

of the RDC/TMD. It is quicker and less sophisticated than the
RDC/TMD and provides an instant physical diagnosis, which
may make it more intuitive and attractive for general dental
practitioners to use in routine clinical practice. The RDC/TMD
remains the gold standard for use in research.

Acknowledgements
The authors would like to thank Mrs. Angela Fenwick for her
expertise in running the research clinics. The authors would
also like to thank the Saudi Cultural Office in London for
sponsoring and supporting the work.

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journal of dentistry 37 (2009) 955962

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