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abstract
Article history:
Objectives: This study aims to assess the reliability, validity and feasibility of a new method
3 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
examiners to reduce the memory effect. Examinations could yield single, multiple or no
Clinical tool
1.
Introduction
* 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
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Fig. 1 Diagnostic criteria for the CEP-TMD derived from the RDC/TMD.
2.
2.1.
Subjects
2.2.
Procedure
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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. 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.
2.3.
Statistical analysis
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.
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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
CEP-TMD
8
21
8
4
7
22
9
3
Kappa
Examiner 1
Examiner 2
Examiner 3
0.71
0.69
0.69
3.2.
Percent agreement
76%
73%
74%
Examination times
4.
Discussion
% 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.
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Table 5 Agreement within and between diagnostic systems (cf. compared with).
RDC/TMD
diagnosis
Upper limit
Upper 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
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
4.1.
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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
5.
Conclusion
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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