Brief Diagnostic Criteria for Temporomandibular disorders (bDC/TMD): Simplifying examination and diagnosis for primary care

Abstract

Early, appropriate diagnosis of temporomandibular disorders (TMD) can influence the course of the condition and help to reduce symptoms. As most patients first present in the primary dental care setting, primary care clinicians should be able to recognise and diagnose TMD. The Brief Diagnostic Criteria for Temporomandibular Disorders (bDC/TMD), published in 2023, was developed to simplify assessment and diagnosis for dental clinicians. This article outlines the clinical assessment, examination and diagnostic steps within the bDC/TMD, and highlights its practical benefits for dental clinicians.

Keywords

Temporomandibular disorder assessment diagnosis primary care

Learning Objectives

To understand the benefits of TMD screening tools

To present a simplified, targeted bDC/TMD examination protocol

To provide and understand the rationale for bDC/TMD grouped TMD diagnoses

Introduction

Temporomandibular disorders (TMD) are the most common non-odontogenic orofacial pain conditions, affecting 10–15% of the adult population.^1,2 Individuals frequently present in the primary care setting with signs and symptoms of TMD; thus, the ability to examine and diagnose these conditions properly is an essential skill. TMD are complex, broad, and multifactorial. A wide range of factors means that presentation between individuals can vary considerably.^1,3 Initiating and perpetuating factors vary between individuals and these factors may also continue to change over the course of the condition.²

To support primary care clinicians, there has been a recent move by international experts to simplify the diagnostic stages of TMD and support decision making with respect to primary care management.^2,4 Early diagnostic certainty is a key target for primary care clinicians to eliminate the risk of unnecessary and potentially harmful treatments, alleviate patient anxiety, and promote understanding and acceptance of the condition by patients, their family and friends.^2,4-6 These factors can, in turn, positively affect both symptom severity and prognosis.^2,4,5 This article outlines the Brief Diagnostic Criteria for TMD (bDC/TMD), explains and justifies the proposed assessment and examination stages, and highlights how its use can streamline and simplify examination and diagnosis.⁴

Diagnostic Criteria for Temporomandibular Disorders (DC/TMD)

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), published in 2014, is the current diagnostic reference standard which, when implemented, can help classify TMD into one of 12 common subtypes (Table 1).⁷ Comprehensive validation has confirmed that the DC/TMD can reliably and consistently diagnose TMD with a high degree of sensitivity and specificity when implemented by trained individuals.^4,7 Unfortunately, despite its clear benefits, DC/TMD utilisation has not translated to the primary care setting and studies have demonstrated low levels of diagnostic confidence in these environments.^4,6,8,9

Table 1

The 12 most common subtypes of TMD with a simplified description for each diagnosis, as outlined by the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD)⁷

Muscle-based TMD		Simplified description
1	Myalgia	Muscular pain
2	Local myalgia	Muscular pain localised to site of palpation
3	Myofascial pain	Muscular pain which spreads beyond site of palpation but stays within the boundary of the muscle being examined
4	Myofascial pain with referral	Muscular pain which spreads beyond the boundary of the muscle being palpated
5	Headache attributed to TMD	Headache in the temporal region which worsens with jaw function
Joint-based TMD		Simplified description
6	DDwR	Disc displaces (usually anterior to the condylar head) then moves back into position. Joint noise (“pop” or “click”) often heard/felt as disc reduces back into place. No locking evident.
7	DDwR with intermittent locking	Disc displaces (usually anterior to the condylar head) then moves back into position. Joint noise (“pop” or “click”) often heard/felt as disc reduces. Disc position stops the jaw from being able to fully open (locking). This locking is usually intermittent and transient.
8	DDwoR with limited opening	Disc displaces (usually anterior to the condylar head) and does not move back into position. The disc position restricts condylar movement so the mouth cannot open all the way (maximum unassisted opening <35mm).
9	DDwoR without limited opening	Disc displaces (usually anterior to the condylar head) and does not move back into position. Despite disc position the mouth can open normally (maximum unassisted opening ⩾35mm).
10	Degenerative joint disease	The breakdown of bone and/or cartilage within the TMJ.
11	Subluxation	Condylar head moves over the articular eminence out of the glenoid fossa. The patient can relocate the dislocated condylar head back into the glenoid fossa themselves.
12	Arthralgia	Pain of joint origin which worsens with jaw use and can be precipitated by palpation over the lateral pole of the TMJ.

DDwR: Disc displacement with reduction; DDwoR: disc displacement without reduction; TMJ: temporomandibular joint.

Brief Diagnostic Criteria for Temporomandibular Disorders (bDC/TMD)

In 2023, members of the International Network for Orofacial Pain and Related Disorders Methodology (INfORM) published the Brief Diagnostic Criteria for Temporomandibular Disorders (bDC/TMD) with the specific aim of supporting clinicians to “expedite clinical diagnosis and initial management”.⁴ While Axis I (physical) and Axis II (psychosocial) assessments are retained, both have been streamlined to support use across all dental care settings. Axis I physical examination, requires a maximum of three jaw movements and three sets of palpations (described below), compared with 25 movements and up to 12 sets of bilateral palpations in the DC/TMD.^4,7 Similarly, Axis II psychosocial assessment has been shortened to 11 items in the bDC/TMD, compared with 79 and 60 items required for the DC/TMD comprehensive and screening assessments respectively.^4,7

Clinical assessment: TMD screening

Screening tools can be particularly useful in primary care to highlight individuals with symptoms suggestive of TMD and identify patients who may benefit from early specialist care. Utilising patient-completed screening tools prior to their appointment in primary care can reduce chairside time while capitalising on the quality of information gathered from patients.

The bDC/TMD incorporates three simple psychosocial screening tools, the Graded Chronic Pain Scale (GCPS),¹⁰ a pain manikin¹¹ and the Patient Health Questionnaire-4 (PHQ-4),¹² alongside a symptom questionnaire. All are accessible online in printable form for clinical use via Durham et al. (see reference 4: Supporting Information, Data S1). Alternatively, a freely-accessible online TMD calculator and screening tool are available via the Royal College of Surgeons of England’s website (see reference 13).^2,13

Graded Chronic Pain Scale (GCPS)

The experience of pain for an individual living with TMD is often cyclical, with fluctuations in intensity noted across a single day, and throughout the course of the condition.³ Such fluctuations mean that objective measures of pain can be very difficult to confirm with the potential of both under- and over-reporting. The modified 30-day GCPS used in bDC/TMD (see Figure 1) offers an objective measure of pain intensity, characteristic pain intensity (CPI), which takes into account such fluctuations.^10,14 It also incorporates a measure of pain-interference, which importantly provides an assessment of the impact of the pain on the individual.^10,14 Completion of GCPS at baseline and appropriate review intervals allows clinicians to accurately monitor progress over time and can become a strong motivational tool for patients to see progress in a condition which can be both physically and emotionally draining. Those recording a score of ⩾80 on the GCPS, which is classified as “severe”, or individuals whose scores for CPI/interference remain unchanged or worsen despite primary care management are likely to warrant referral to secondary care services for specialist assessment alongside ongoing primary care management in a bid to provide every available option for progress with their condition.^2,15

Appropriate review intervals for TMD should be determined by clinicians on an individual basis. Recently published guidelines by the Royal College of Surgeons of England recommend that an initial review is undertaken 6–8 weeks following baseline assessment.² This period allows sufficient time for patient engagement with, and utilisation of, supported self-management strategies. Review and reassessment at this time point enables clinicians to determine whether continuation of conservative care is appropriate or whether additional management strategies, such as splint provision, should be introduced. This approach aims to optimise intervention during the acute phase of pain (<3 months), where treatment benefit is most likely and where timely, targeted care may help prevent the transition from acute to chronic pain.

Onward review intervals should be discussed and determined with the patient. For individuals with stable TMD, reviewing current symptoms and updating management strategies at the same time as their planned 6- or 12-monthly dental health check appointments seems sensible and pragmatic. For those with more pronounced pain or functional issues it would be sensible to review more regularly to provide reassurance, advice and appropriate supportive care and management.

Pain manikin

Figure 2, illustrates the bDC/TMD pain manikin. Patients are encouraged to annotate the images to demonstrate the location of their pain.^4,11 Pain manikins can help with diagnosis, as demonstrated in Figures 3a and 3b, and highlight individuals who may have wider issues with systemic pain conditions or pain processing (Figure 3c). The self-reporting of significant systemic pain on pain manikins should trigger further verbal exploration by the clinician. Individuals with a known longstanding medical diagnosis (e.g. fibromyalgia or rheumatoid arthritis) may already be under specialist medical review and management, thus information sharing with the medical specialism responsible for the patient regarding the intended management of their TMD symptoms in primary dental care may be the only required action. For those who have no diagnosis or perhaps have not sought prior medical support, onward referral to their general medical practitioner to request medical assessment should be completed. It would be beneficial to provide supportive information as part of this referral, such as the patient’s current symptoms and copies of pain assessment data (i.e. GCPS, pain manikin and PHQ-4). It is important that referral or information sharing for such cases is completed alongside initiation of appropriate TMD management and review in primary dental care.

Patient Health Questionnaire-4 (PHQ-4)

The final recommended bDC/TMD screener is the PHQ-4. This brief four-item questionnaire (Table 2) aims to assess for symptoms of psychosocial distress, i.e. anxiety and depression.¹² It is widely recognised that individuals who display psychosocial comorbidities are more likely to present with TMD and their TMD is more likely to become persistent.^2,16-19 Furthermore, the presence of psychosocial factors, and the extent to which they are managed, is considered as influential on TMD treatment outcomes as physical factors.¹⁶ Although the importance of psychosocial assessment is widely accepted, some dental clinicians may feel uncomfortable having conversations with patients on issues such as depression and anxiety. Incorporating the PHQ-4 supports dental clinicians by making it easier for them to approach patients’ psychosocial factors in primary care. The PHQ-4 score, and its meaning should be discussed openly with patients. Individuals with a PHQ-4 score of 9–12, suggesting severe symptoms of psychosocial distress, should be referred to general medical teams for formal assessment.^2,12 Referral for those with lower PHQ-4 scores who request help is also entirely appropriate. The recently published NHS England Getting It Right First Time (GIRFT) and Royal College of Surgeons of England Faculty of Dental Surgery’s “Management of painful temporomandibular disorder in adults” guideline provides template referral letters which can be used by dental clinicians to support referral based on PHQ-4 scores.²

Table 2

Patient Health Questionnaire-4 (PHQ-4)¹²

Over the PAST 2 WEEKS have you been bothered by these problems?Please cross ONLY one box for each question
	Not at all	Several days	More than half the days	Nearly every day
1) Feeling nervous, anxious, or on edge
2) Not being able to stop or control worrying
3) Feeling down, depressed, or hopeless
4) Little interest or pleasure in doing things

“Not at all” scores 0; “several days” scores 1; “more than half the days” scores 2; “nearly every day” scores 3. Cumulative score for question 1–4 represents a numeric value of symptoms of anxiety and/or depression: Normal (0–2), mild (3–5), moderate (6–8), severe (9–12).

Symptom questionnaire

The aim of the bDC/TMD screening questionnaire is to support identification of TMD, and highlight potentially implicated anatomical structures (e.g. muscles, joint or disc) aiding diagnosis.⁴ As previously stated, the bDC/TMD symptom questionnaire is freely accessible online via Durham et al. (Supporting Information, Data S1), and printed copies can be provided to patients.⁴ If, for any reason, integration of the bDC/TMD symptom questionnaire is not feasible, the use of targeted verbal screening questions during history taking, as those outlined in Table 3, would support the diagnostic process in primary care in a similar fashion.

Table 3

Key screening questions expected to support TMD diagnosis and their justification^3,4,20

Negative response to any “pArt a” question, proceed to next numeric question

Question	Justification
1a Do you have pain in your jaw, temple, within or in front of your ear? (regional pain)	These are the most common locations for pain experienced by those with TMD.Negative response makes TMD unlikely to be causative issue of patient’s pain.
1b How long have you had this pain?	Determines whether the issue is acute (<3 months) or persistent (⩾3 months)
2 Do activities that use the jaw (e.g. talking, chewing, yawning) worsen your pain?	Confirms pain modification with jaw use, which would be expected with TMD.If not present it is less likely that TMD is causative issue.
3 Do you have headaches which present in your temple?	25% of TMD present as isolated headache.Headache attributed to TMD presents in temporal region.Headache in other regions suggestive of comorbid primary headache condition and not TMD.
4 Do activities that use the jaw (e.g. talking, chewing, yawning) worsen your headache?	Confirms pain modification with jaw use, which would be expected with headache attributed to TMD.If not, present headache is more likely a separate comorbid primary headache condition and the patient could be signposted to their general medical team for headache assessment as appropriate.
5a When you move and use your jaw are you aware of any noises from the jaw joint?	Positive confirmation suggests disc or joint issue
5b Does the noise feel/sound like a “pop” or a “click”?	Suggests a disc displacement
5c Does the noise feel/sound like grating/grinding?	Suggests degenerative joint disease (DJD)
5d Is there any pain with the joint noise?	Disc displacements and DJD are pain-free in many cases. For such cases management is likely to include education as to the cause of the noise and reassurance around the fact that arthrogenous TMDs tend to have positive prognosis.
6a Has your jaw ever locked closed, so that you were unable to open it fully, even for a moment?	Positive confirmation suggests disc issue, either disc displacement with reduction (DDwR) with intermittent locking or disc displacement without reduction (DDwoR).
6b Is your jaw currently locked so it feels like you cannot open it fully?	Suggests DDwoR with limited opening or severe myogenous TMD with muscular guarding.
6c Did it quickly unlock so you were then able to open fully?	Suggests DDwR with intermittent locking
7a Has your jaw ever locked wide open so you could not close it?	Suggests dislocation
7b What did you do to enable it to close again?	Any patient factor which enabled closing (e.g. resting, moving, pushing) confirms subluxation.If required, a clinician (medical or dental) to manipulate jaw to close confirms luxation.

TMD-specific physical examination

Visual extra-oral assessment, palpation for lymphadenopathy, examination of intra-oral soft tissues, periodontal and dental structures would be expected to be followed as part of a routine dental examination. Specific for the diagnosis of TMD, the temporomandibular joint (TMJ) and muscles of mastication must also be examined, a process which the bDC/TMD has simplified significantly. Reproduction of “familiar pain” – pain which represents the patient’s complaint – when examining each anatomical structure should remain the focus for clinicians.^2,7 If familiar pain or headache cannot be elicited during examination of the TMJ, masseter and/or temporalis muscles, then it is unlikely that the pain diagnosis relates to TMD, and other potential diagnoses should be explored.

Temporomandibular joint (TMJ)

The TMJ is examined from its lateral aspect through application of gentle pressure over the skin just anterior to the tragus of the ear, firstly with the mouth closed (Figure 4a). As pressure is maintained in the same position by the clinician, the patient is asked to open and close their mouth. During mandibular movement the clinician should assess for:

Presence of joint noises

Presence of joint lock

Pain-free opening (measured inter-incisally in mm)*

Maximum unassisted opening (measured inter-incisally in mm)**

* The patient is asked to open their mouth as wide as they can without triggering pain, and measurement taken.

**The patient is asked to open as wide as they can even if pain is felt, and measurement taken.

A maximum of three opening and closing cycles should be completed. Should a joint noise and/or lock be identified at any point, no further movements are necessary.⁴ Lateral and protrusive mandibular movements demonstrate low reliability, as patients often find these movements difficult to perform consistently.²¹ Studies have also reported wide variability in measurements when these movements are recorded by trained clinicians on the same patients.²² Due to these limitations, and because the results rarely contribute meaningfully to diagnosis, these movements have been removed from the bDC/TMD examination.^4,23

Masseter and temporalis

Due to poor levels of diagnostic sensitivity and specificity for other muscles of mastication, bDC/TMD advocates examination of only the masseter and temporalis muscles.⁷ The body of masseter (Figure 4b) and anterior aspect of temporalis (Figure 4c) should be palpated for a few seconds, specifically assessing for familiar pain.⁴ Extension of the examination to other aspects of these muscles can be completed but is not required.⁴

Other important examination considerations

The only remaining factors that all clinicians need to be mindful of is that in very rare instances sinister or malignant pathology can masquerade as TMD.^24,25 There are widely publicised “red flag” features for TMD, summarised here:²

history of previous malignant tumour with facial pain or headache

lymphadenopathy

face or neck mass/swelling

jaw claudication (cramp-like pain in tongue or jaw)

unplanned weight loss

pyrexia

acute onset profound, or worsening, trismus

neurological signs/symptoms (acute onset loss of smell or hearing, visual problems, neurosensory change, motor weakness)

persistent and profuse nasal bleeding or discharge

hoarseness of the voice (⩾3 weeks)

persistent mouth ulcer(s) (⩾3 weeks)

new onset jaw pain in those taking bisphosphonates or related medication

Should any “red flag” sign or symptom be detected, urgent referral to appropriate medical teams must be arranged.²

Diagnosis

The bDC/TMD focuses on clinicians being able to classify presenting TMD into two broad overarching groups (muscle-based or joint-based TMD) rather than the more complex DC/TMD subtypes (Table 1).^4,7 Findings from TMD history and examination can be fed directly in the bDC/TMD decision trees (Figures 5 and 6) to classify TMD as either:

Painful TMD

Common joint-related TMD with implications for function

The diagnosis requires confirmatory findings in both patient history and clinical examination.

Painful TMD

Painful TMD represents myalgia, arthralgia and headache attributed to TMD, simplified definitions of which are provided in Table 1.⁴ Figure 5 shows these sub diagnoses all positively report pain or headache in the correct region (jaw, temple, within or in front of the ear) which is modified by jaw function. Confirmation of “familiar” pain or headache when examining the TMJs, masseter and/or temporalis muscles positively relates the complaint to the examined structure and is required for establishing a diagnosis.

Common joint-related TMD with implications for function

Common joint-related TMD with implications for function represents degenerative joint disease, disc displacement without reduction and with limited opening, subluxation and a combined group of all other disc-based TMD.⁴ Figure 6 shows how important a targeted TMD history is to identify specific clinical signs for joint-related TMD (e.g. type of lock – open or closed) which, when added to positive examination findings, facilitates diagnostic confirmation.

Justification for use of bDC/TMD broad group diagnosis in primary care

The freedom to diagnose using one of two broad diagnostic groups – painful TMD or joint-related TMD with implication for function is undoubtedly simpler for clinicians in time-pressurised clinical environments. From both a patient and clinician perspective, management of pain and maintenance of function tend to be the main drivers for care provision, meaning that the bDC/TMD broad group diagnoses align with population expectations for care provision.² Furthermore, initial evidence-based management would be consistent for the sub diagnoses within the broad groups and so further subclassification in the primary care setting would not be expected to change initial TMD management strategies.²

Summarised bDC/TMD assessment and examination protocol

Below is an assessment summary, outlining how the bDC/TMD can be integrated into clinical practice. This can be used as a clinical aid for clinicians new to the bDC/TMD and demonstrates how quick and simple the bDC/TMD is.

The patient is asked to complete the below screening documents prior to entry into surgery:

Graded Chronic Pain Scale (GCPS)

Pain manikin

Patient Health Questionnaire-4 (PHQ-4)

TMD symptom questionnaire

Clinician examination:

Clinician reviews and discusses screening results with patient

Screening results likely to provide diagnostic clues to explore further in examination process.

2. Additional targeted verbal TMD screening questions (Table 3) can be used as required by clinicians to clarify history

3. Complete routine extra- and intra-oral examination

4. Palpate lateral pole of TMJ bilaterally*

5. Ask patient to open and close mandible a maximum of three times

a. Feel and listen for joint noise and/or joint lock, stop movements if positive confirmation.

6. Measure pain-free opening (mm)

7. Measure maximum unassisted opening (mm)

8. Palpate body of masseter and anterior aspect of temporalis (2s per muscle)*

9. Document findings in clinical notes

10. Refer to bDC/TMD decision trees for diagnostic support

11. Provide and explain diagnosis and initiate first stage management

*Specifically assess for familiar pain

Conclusion

When used correctly, the bDC/TMD offers the opportunity for clinicians to gather targeted, relevant information with reduced clinician and patient burden.⁴ The freely available resources (screening/assessment tools and diagnostic decision trees) aim to support integration of bDC/TMD into routine clinical practice offering the potential for expedited diagnosis and improved clinical outcomes for individuals presenting with TMD in the future.

Footnotes

Declaration of conflicting interest

The author declares no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

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