validly provide diagnoses for most individuals with TMD

pain. Imaging will be required to establish a disc disorder

diagnosis such as disc displacement without reduction.
See Table 11-4 for validated imaging criteria. The clinician
should recommend diagnostic imaging as part of the assessment
when the prognosis or choice of treatment might benefit.
The reader is referred to the publication by Schiffman et
al. for a full description of the DC/TMD, by Peck et al. for
DC for the less common TMD, by DeLeeuw and Klasser
for a comprehensive guidebook to evaluation, diagnosis, and
treatment, and the website of the International RDC-TMD
Consortium Network (http://rdc-tmdinternational.org/) for
clinical examination specifications, training video, and all
patient assessment instruments.

ASSESSMENT

Although examination methods have been traditionally

considered to lack the ability to accurately differentiate individuals
with a TMD from those without TMD,204 recent
developments have dramatically changed the diagnostic
terrain of TMD. The most valuable aspect of the diagnostic
assessment is a thorough history205; pain disorder diagnoses
rely predominantly on the history, and the diagnosis of some
pain disorders, for example, headache, relies exclusively on
the history.206 For some disorders (e.g., headache), the history
serves to rule out other forms of pathology; for TMD,
the examination is now confirmatory for a pain diagnosis
but remains only suggestive for most of the joint disorders.
An examination for a particular disorder (e.g., the comprehensive
examination of TMD, as described201) must be
supplemented by examination procedures as needed for a
differential diagnosis, for example, ruling out odontogenic
causes of regional masticatory system pain. In contrast to the
situation 20 years ago when TMD diagnostic tests were not
validated or standardized,197 the clinical tests most needed
for the assessment of a person with TMD are now standardized,
reliable, and valid.195,207 In contrast, diagnostic tests
such as ultrasonography of joint sounds, thermography, jaw
tracking, and EMG, all of which exhibit high measurement
reliability and precision, do not offer the assurance of a more
accurate diagnosis or better treatment outcomes.208 These
devices were reviewed for their diagnostic value in assessing
patients with temporomandibular complaints and were
judged 20 years ago to not have the necessary sensitivity and
specificity for a valid diagnosis.205 No additional supporting
evidence has emerged over the past several decades. However,
claims that they are adjunctive tests must be accompanied
by the same evidence as required for any diagnostic
test; if an adjunctive test is to be useful, incremental validity
must be demonstrated. Incremental validity refers to the
ability of an additional test to provide unique information
that improves the sensitivity or specificity of the information
obtained prior to the additional test. For example, analysis of
TMJ synovial fluid is an active area of research but has not
yet become a standard procedure in diagnosis or the selection

Table 11-2 Diagnostic Criteria for the Most Common Pain-Related Temporomandibular
Disorders
Myalgia (ICD-9 729.1)
Description Pain of muscle origin that is affected by jaw movement, function, or parafunction, and replication of this
pain occurs with
provocation testing of the masticatory muscles.
Criteria
History
and
Exam
1. Paina in the jaw, temple, in the ear, or in front of ear; and
2. Pain modified with jaw movement, function or parafunction.
1. Confirmationb of pain location(s) in the temporalis or masseter muscle(s); and
2. Report of familiar painc in the temporalis or masseter with at least one of the following provocation tests:
a. Palpation of the temporalis or masseter muscle(s); or
b. Maximum unassisted or assisted opening.
Validity Sensitivity 0.90; specificity 0.99
Comments The pain is not better accounted for by another pain diagnosis. Other masticatory muscles may be
examined as dictated by
clinical circumstances but the sensitivity and specificity for this diagnosis based on these findings has not been
established.
Myofascial Pain with Referral (ICD-9 729.1)
Description Pain of muscle origin as described for myalgia with referral of pain beyond the boundary of the
masticatory muscle(s) being
examined when using the myofascial examination protocol. Myofascial pain with referral is a subtype of myalgia.
Criteria
History
and
Exam
1. Paina in the jaw, temple, in the ear, or in front of ear; and
2. Pain modified with jaw movement, function, or parafunction.
1. Confirmationb of pain location(s) in the temporalis or masseter muscle(s); and
2. Report of familiar painc with palpation of the temporalis or masseter muscle(s); and
3. Report of pain at a site beyond the boundary of the muscle(s) being palpated.
Validity Sensitivity 0.86; specificity 0.98
Comments The pain is not better accounted for by another pain diagnosis. Other masticatory muscles may be
examined as dictated by
clinical circumstances, but the sensitivity and specificity for this diagnosis based on these findings has not been
established.
Arthralgia (ICD-9 524.62)
Description Pain of joint origin that is affected by jaw movement, function, or parafunction, and replication of this
pain occurs with
provocation testing of the TMJ.
Criteria
History
and
Exam
1. Paina in the jaw, temple, in the ear, or in front of ear; and
2. Pain modified with jaw movement, function, or parafunction.
1. Confirmationb of pain location in the area of the TMJ(s); and
2. Report of familiar painc in the TMJ with at least one of the following provocation tests:
a. Palpation of the lateral pole or around the lateral pole; or
b. Maximum unassisted or assisted opening, right or left lateral movements, or protrusive movements.
Validity Sensitivity 0.89; specificity 0.98
Comments The pain is not better accounted for by another pain diagnosis.
Headache attributed to TMD (ICD-9 339d)
Description Headache in the temple area secondary to pain-related TMD e that is affected by jaw movement,
function, or parafunction, and
replication of this headache occurs with provocation testing of the masticatory system.
Criteria
History
and
Exam
1. Headache1 of any type in the temple; and
2. Headache modified with jaw movement, function, or parafunction.
1. Confirmationb of headache location in the area of the temporalis muscle(s); and
2. Report of familiar headachec in the temple area with at least one of the following provocation tests:
a. Palpation of the temporalis muscle(s); or
b. Maximum unassisted or assisted opening, right or left lateral movements, or protrusive movements.

Validity Sensitivity 0.89; specificity 0.87

Comments The headache is not better accounted for by another headache diagnosis.
Abbreviations: ICD, International Classification of Diseases; TMD, temporomandibular disorder. TMJ,
temporomandibular joint.
aThe time frame for assessing pain including headache is in the last 30 days since the stated sensitivity and
specificity of these criteria were
established using this time frame. Although the specific time frame can be dependent on the context in which the
pain complaint is being
assessed, the validity of this diagnosis based on different time frames has not been established.
bThe examiner must identify with the patient all anatomical locations that they have experienced pain in the last 30
days. For a given
diagnosis, the location of pain induced by the specified provocation test(s) must be in an anatomical structure
consistent with that diagnosis.
cFamiliar pain or familiar headache is based on patient report that the pain induced by the specified provocation
test(s) has replicated the
pain that the patient has experienced in the time frame of interest, which is usually the last 30 days. Familiar pain
is pain that is similar or
like the patients pain complaint.
dThe ICD-9 has not established a specific code for Headache attributed to TMD; ICD-9 339 is for other headache
syndromes. If a primary
headache is present (e.g., tension type headache), then the headache can be classified according to the primary
headache type.
eA diagnosis of painful TMD (e.g., myalgia, myofascial pain with referral, or TMJ arthralgia) is derived using valid
diagnostic criteria.
Source: Reprinted by permission of J Oral & Facial Pain and Headache

Table 11-3 Diagnostic Criteria for the Most Common Intra-articular Temporomandibular
Disorders
Disc Displacement With Reduction (ICD-9 524.63)
Description An intra-capsular biomechanical disorder involving the condyledisc complex. In the closed mouth
position, the disc is in
an anterior position relative to the condylar head, and the disc reduces upon opening of the mouth. Medial and
lateral
displacement of the disc may also be present. Clicking, popping, or snapping noises may occur with disc reduction.
A
history of prior locking in the closed position coupled with interference in mastication precludes this diagnosis.
Criteria
History
and
Exam
1. In the last 30 days,a any TMJ noise(s) present with jaw movement or function,
or
2. Patient report of any noise present during the exam.
1. Clicking, popping and/or snapping noise detected during both opening and closing, with palpation during at least
one
of three repetitions of jaw opening and closing;
or
2. Clicking, popping, and/or snapping noise detected with palpation during at least one of three repetitions of
opening or
closing; and
3. Clicking, popping, and/or snapping noise detected with palpation during at least one of three repetitions of right
or left
lateral movements, or protrusive movements.
Validity Without imaging: sensitivity 0.34; specificity 0.92.
Imaging is the reference standard for this diagnosis.
Imaging
When this diagnosis needs to be confirmed, then TMJ MRI criteria 252 are positive for both of the following:
1. In the maximum intercuspal position, the posterior band of the disc is located anterior to the 11:30 position and
the
intermediate zone of the disc is anterior to the condylar head;
and
2. On full opening, the intermediate zone of the disc is located between the condylar head and the articular
eminence.
Disc Displacement With Reduction With Intermittent Locking (ICD-9 524.63)
Description An intracapsular biomechanical disorder involving the condyledisc complex. In the closed mouth
position, the disc is in an
anterior position relative to the condylar head, and the disc intermittently reduces with opening of the mouth. When
the

disc does not reduce with opening of the mouth, intermittent limited mandibular opening occurs. When limited
opening
occurs, a maneuver may be needed to unlock the TMJ. Medial and lateral displacement of the disc may also be
present.
Clicking, popping, or snapping noises may occur with disc reduction.
Criteria
History
and
Exam
In the last 30 days,a any TMJ noise(s) present with jaw movement or function;
or
Patient report of any noise present during the exam.
and
In the last 30 days,a jaw locks with limited mouth opening, even for a moment, and then unlocks.
Same as specified for Disc Displacement with Reduction. Although not required, when this disorder is present
clinically,
examination is positive for inability to open to a normal amount, even momentarily, without the clinician or patient
performing a specific manipulative maneuver.
Validity Without imaging: sensitivity 0.38; specificity 0.98.Imaging is the reference standard for this diagnosis.
Imaging When this diagnosis needs to be confirmed, then the imaging criteria 252 are the same as for disc
displacement with reduction
if intermittent locking is not present at the time of imaging. If locking occurs during imaging, then an imaging-based
diagnosis of disc displacement without reduction will be rendered and clinical confirmation of reversion to
intermittent
locking is needed.
Disc Displacement Without Reduction With Limited Opening (ICD-9 524.63)
Description An intracapsular biomechanical disorder involving the condyledisc complex. In the closed mouth
position, the disc is in
an anterior position relative to the condylar head, and the disc does not reduce with opening of the mouth. Medial
and
lateral displacement of the disc may also be present. This disorder is associated with persistent limited mandibular
opening
that does not resolve with the clinician or patient performing a specific manipulative maneuver. This is also referred
to as
closed lock.
Criteria
History
and
Exam
1. Jaw lock or catch so that the mouth would not open all the way; and
2. Limitation in jaw opening severe enough to limit jaw opening and interfere with ability to eat.
Maximum assisted opening (passive stretch) <40 mm including vertical incisal overlap.
Validity Without imaging: sensitivity 0.80; specificity 0.97. Imaging is the reference standard for this diagnosis.
Imaging When this diagnosis needs to be confirmed, then TMJ MRI criteria 252 are positive for both of the following:
1. In the maximum intercuspal position, the posterior band of the disc is located anterior to the 11:30 position and
the
intermediate zone of the disc is anterior to the condylar head, and
2. On full opening, the intermediate zone of the disc is located anterior to the condylar head.
Note: Maximum assisted opening of <40 mm is determined clinically.
Footnote Presence of TMJ noise (e.g., click with full opening) does not exclude this diagnosis.

Table 11-3 Diagnostic Criteria for the Most Common Intra-articular Temporomandibular
Disorders (Continued)
Disc Displacement Without Reduction Without Limited Opening (ICD-9 524.63)

Description An intracapsular biomechanical disorder involving the condyledisc complex. In the closed mouth
position, the disc is
in an anterior relative the condylar head and the disc does not reduce with opening of the mouth. Medial and lateral
displacement of the disc may also be present. This disorder is not associated with limited mandibular opening.
Criteria
History
and
Exam
Same as specified for Disc Displacement Without Reduction With Limited Opening.
Maximum assisted opening (passive stretch) >40 mm including vertical incisal overlap.
Validity Without imaging: sensitivity 0.54; specificity 0.79.Imaging is the reference standard for this diagnosis.
Imaging When this diagnosis needs to be confirmed, then TMJ MRI criteria 252 are the same as for disc displacement
without reduction
with limited opening.

Note: Maximum assisted opening of 40 mm is determined clinically.

Footnote Presence of TMJ noise (e.g., click with full opening) does not exclude this diagnosis.
Degenerative Joint Disease (ICD-9 715.18)
Description A degenerative disorder involving the joint characterized by deterioration of articular tissue with
concomitant osseous
changes in the condyle and/or articular eminence.
Criteria
History
and
Exam
1. In the last 30 daysa any TMJ noise(s) present with jaw movement or function;
or
2. Patient report of any noise present during the exam.
At least one of the following must be present:
1. Crepitus detected with palpation during opening, closing, lateral, or protrusive movements.
Validity Without imaging: sensitivity 0.55; specificity 0.61. Imaging is the reference standard for this diagnosis.
Imaging When this disorder is present, then TMJ CT criteria 252 are positive for at least one of the following:
Subchondral cyst(s),
erosion(s), generalized sclerosis, or osteophyte(s). Note: Flattening and/or cortical sclerosis are considered
indeterminant
findings for DJD and may represent normal variation, aging, remodeling, or a precursor to frank DJD.
Subluxation (ICD-9 830.1)
Description A hypermobility disorder involving the disc-condyle complex and the articular eminence: In the open
mouth position, the
disc-condyle complex is positioned anterior to the articular eminence and is unable to return to a normal closed
mouth
position without a specific manipulative maneuver. The duration of dislocation may be momentary or prolonged.
When
prolonged the patient may need the assistance of the clinician to reduce the dislocation and normalize jaw
movement; this
is referred to as luxation. This disorder is also referred to as open lock.
12
History
and
Exam
1. In last 30 days,a jaw locking or catching in a wide open mouth position, even for a moment, so could not close
from the
wide open position; and
2. Inability to close the mouth without a specific manipulative maneuver
Although no exam findings are required, when this disorder is present clinically, examination is positive for inability
to return
to a normal closed mouth position without the patient performing a specific manipulative maneuver.
Validity Without imaging and based only on history: sensitivity 0.98; specificity 1.00.
Imaging When this disorder is present, then imaging criteria are positive for the condyle positioned beyond the
height of the articular
eminence.
Abbreviations: CT, computed tomography; DJD, degenerative joint disease; ICD, International Classification of
Diseases; MRI, magnetic
resonance imaging; TMD, temporomandibular disorder; TMJ, temporomandibular joint.
aThe time frame for assessing selected biomechanical intra-articular disorders is in the last 30 days since the
stated sensitivity and specificity
of these criteria was established using this time frame. Although the specific time frame can be dependent on the
context in which the pain
complaint is being assessed, the validity of this diagnosis based on different time frames has not been established.
Source: Reprinted with permission from Journal of Oral & Facial Pain and Headache.

of treatment. These tests require sophisticated instrumentation

that would increase health care costs to the patient that,
for the present, are not justified.
Consequently, history, clinical examination, and imaging
when indicated remain the recommended diagnostic approach
for most patients.109,210 Diagnostic imaging is of value in
selected conditions but not as a routine part of a standard
assessment. Diagnostic imaging can increase accuracy in the
detection of internal derangements211 and abnormalities of
articular bone.212 The clinical meaningfulness of such tests,

however, must be determined prior to ordering the test; a

special test should be preceded by a clinical hypothesis (differential
diagnosis) that the test will be able to answer, and
the clinical hypothesis should be related to a particular course
of action. For example, if treatment for what appears to be a
painful recurrent mechanical joint problem will proceed in one
Table 11-4 Imaging-Based Diagnosis of Soft- and Hard-Tissue TMJ Disorders
Disorder Criteria

Disc diagnosis for the TMJ, based on MRIa

Normal Disc location is normal on closed and open mouth images.
Disc displacement with reduction Disc location is displaced on closed mouth images but normal on open mouth
images
Disc displacement without reduction Disc location is displaced on both closed mouth and open mouth images.
Indeterminate Disc location is not clearly normal or displaced in the closed mouth view
Disc not visible Neither signal intensity nor outlines make it possible to define a structure as the disc in the
closed mouth and open mouth views. If the images are of adequate quality in visualizing
other structures in the TMJ, then this finding is interpreted to indicate a deterioration of the
disc, which is associated with advanced disc pathology.
Osseous diagnoses for the TMJ, based on CT b
Normal a. Normal relative size of the condylar head; and
b. No subcortical sclerosis or articular surface flattening; and
c. No deformation due to subcortical cyst, surface erosion, osteophyte, or generalized
sclerosis.
Indeterminate for osteoarthritis a. Normal relative size of the condylar head; and
b. No deformation due to subcortical cyst, surface erosion, osteophyte, or generalized
sclerosis; and
c. Either of:
i. Subcortical sclerosis; or
ii. Articular surface flattening
Osteoarthritis a. Deformation due to subcortical cyst, surface erosion, osteophyte, or generalized sclerosis
Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; TMJ, temporomandibular joint.
aAdapted from Table IV, Ahmad et al.252
bAdapted from Table II, Ahmad et al.252

direction if the problem is a disc displacement but in another

direction if the disc is normal, then imaging would be well
justified. If, on the other hand, both treatments for this stated
example would be pursued, each for four to six weeks and with
no or minimal risk of adverse effects, then the treatment trial
without imaging may be more prudent, thereby not unnecessarily
expending health-care resources. A painful clicking
joint should be treated, regardless of whether the problem is
due to an internal derangement.68 If the choice of treatment
depends on a more accurate diagnosis, then imaging would be
indicated.
Similarly, other tests should be ordered when the differential
diagnosis warrants further diagnostic exploration.
Examples follow. Facial pain similar to the pain of a TMD
may be associated with serious undetected disease. Muscle
or joint pain may be a secondary feature of another disease
or may mimic a TMD. A diagnosis of a more serious condition
may be missed or delayed.213,214 Severe throbbing
temporal pain associated with a palpable nodular temporal
artery, increasingly severe headache associated with nausea
and vomiting, and documented altered sensation or hearing
loss are all indications of serious disease requiring timely
diagnosis and management. Table 11-5 lists, for many
TMDs, characteristics which, if present and clinically significant,
may require focused assessment in conjunction
with the standard evaluation. In short, TMD diagnosis (and

management) requires ongoing use of clinical decision-making

skills.

History
The most common symptom related to TMD is pain, and it
is the overwhelming reason why people seek care. Pain may
be present at rest, may be continuous or intermittent, and
characteristically increases with jaw functions such as chewing
or opening wide. Reported pain among community cases
is somewhat lower in intensity compared to clinic cases, 163
suggesting that processes that affect pain amplification or
pain modulation differ across time, and eventually a community
case will decide to seek care. Other chief complaints
in relation to seeking care for a TMD include restricted jaw
movement (independent of pain), painful or loud TMJ clicking
or crepitus, and jaw locking.
Pain severity or intensity is a subjective measure provided
by the patient and can be rated in several ways.215 A rating
scale can be either numeric or verbal. A numeric scale asks
the patient to rate pain by identifying a number, typically
between 0 and 10, that best reflects pain intensity. Verbal
descriptors such as no pain, mild pain, moderate pain, and
severe pain can also provide an equally valid assessment. If an
estimate with greater precision is needed, a visual analogue
scale (VAS) can provide an estimate that has high sensitivity
to change and better independence when using repeated
measures. A VAS uses a 10-cm line anchored on the left side
with the descriptor of no pain and on the right an extreme
descriptor such as the worst pain ever experienced. The
patient is asked to mark his or her pain intensity by placing
a mark on the line, and the score is obtained by measuring
Table 11-5 Selected TM Disorders and Supplemental Characteristics
Disorder Characteristics

Deviation in form
Note: Painless mechanical dysfunction or altered function due to
irregularities or aberrations in the form of intracapsular soft and
hard articular tissues. Does not require intervention.

Complaint of faulty or compromised joint mechanics

Reproducible joint noise, usually at the same position during

opening and closing

Radiographic evidence of structural bony abnormality or loss of

normal shape
Disc displacement with reduction
Note: Clinical significance is related to pain associated with the noise,
to mechanical locking, or interference in mastication or other
functional activities.

Pain (when present) is directly associated with joint noise during

movement

Clinical assessment is often unreliable due to poor stability of the

noise

Mandibular deviation during opening or closing coinciding with

a click
Disc displacement without reduction

History of clicking that stopped when the locking began

Pain clearly localized to the TMJ precipitated by function, when

acute

Marked limited mandibular opening when acute

Uncorrected deviation to the affected side on opening and marked

limited laterotrusion to the contralateral side when acute

Localized pain precipitated by forced mouth opening

Ipsilateral hyperocclusion, when acute

Synovitis or capsulitis
Note: Inflammation of the synovial lining or loading of capsular
lining. Difficult to clearly differentiate from arthralgia.

Localized pain at rest exacerbated by function, especially with

superior and posterior joint loading

Limited range of motion secondary to pain

Crepitus on examination

T2-weighted MRI may show joint fluid

Osteoarthrosis
Note: Degenerative noninflammatory condition of the joint,
characterized by structural changes of joint surfaces secondary to
excessive strain on the remodeling mechanism. Distinguish from
osteoarthritis, which is a secondary inflammatory condition. Both
osteoarthrosis and osteoarthritis are subsumed within degenerative
joint disease in the DC/TMD.
Absence of joint pain
Myofascial pain
Note: Is a regional disorder, distinguishing it from fibromyalgia. When
the pain is local to the area of stimulation, this disorder is termed
myalgia in the DC/TMD to note the presence of hyperalgesia
without spreading, referral, or autonomic reactions. The clinical
significance of these additional characteristics is with differential
diagnosis; the requirement for specific treatments when referral is
present remains untested but anecdotally rich.

Taut bands and trigger points are hallmark characteristics but

exhibit only fair examiner reliability

Reduction in pain with local muscle anesthetic injection or

vapocoolant spray, coupled with stretch of the muscle
Protective muscle splinting
Note: Restricted or guarded mandibular movement due to cocontraction
of muscles as a means of avoiding pain caused
by movement of the parts. Should be distinguished from fearavoidance
behavior by ruling out local nociceptive source, by
either history or examination.

Severe pain with function but not at rest

Limited range of motion

Marked limited range of motion (generally, pain-free opening

and maximal unassisted opening will be similar), and opening is
only minimally responsive to attempted passive stretch (maximal
assisted opening) initially, and active resistance to further attempts
at stretch can be noted
Contracture
Note: Chronic resistance of a muscle to passive stretch as a result
of fibrosis of the supporting tendon, ligaments, or muscle fibers
themselves.
Unyielding firmness on passive stretch

History of trauma or infection

Abbreviations: DC/TMD, diagnostic criteria for temporomandibular disorder; MRI, magnetic resonance imaging; TMJ,
temporomandibular joint.
Source: Adapted from McNeill.198

from the left end to the mark. Any of these rating scales can
be used to assess current, minimum and maximum in the
past, or average pain ratings. For rating prior periods (past
minimum and maximum, average), a time span is required;
common ones are last 30 days, last 3 months, and last
6 months. The DC/TMD explicitly uses the last 30 days

for two reasons: memory for prior pain is better with shorter
time periods, and in general, the last 30 days is sufficient for