Clinical Relevance Of RDC Diagnostic Tool In Current Clinical Environment: Temporomandibular Disorder Study - A Point Pandect

Keywords

Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD); Temporomandibular Disorders (TMD); Temporomandibular Joint (TMJ); Diagnosis; Awareness.

Introduction

TMJ disorders (TMD) are a class of degenerative musculoskeletal conditions associated with morphological and functional deformities [1-5]. TMD include abnormalities of the intra-articular discal position and/or structural dysfunction of the associated musculature [6-10]. Symptoms and signs include painful joint sounds, restricted or deviating range of motion, and cranial and/or muscular pain known as orofacial pain [11-14]. Due to the complex and unique nature of every TMD case encountered, its diagnosis requires patient-specific analysis which should be accompanied by various diagnostic modalities.

Since the American Dental Association’s president’s conference on temporomandibular disorders (TMDs) in 1983, every major forum on this topic has highlighted the need for a reliable and valid diagnostic classification system to identify TMD cases, including specific subtypes [15]. In particular, the National Institutes of Health Technology Assessment Conference Statement on the Management of Temporomandibular Disorders released in 1996 articulated the need for epidemiological and experimental studies to determine the etiologic mechanisms of and risk factors for TMDs [16]. Results from such studies would provide the basis for an etiology-based diagnostic classification system necessary to best facilitate clinical research leading to improved management and treatments for these disorders [11-14].

The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) are a widely employed diagnostic protocol for TMD research [7]. This taxonomic system includes an Axis I physical assessment and diagnostic protocol and an Axis II assessment of psychological status and pain-related disability [7, 17]. The (RDC/TMD) presented by Dworkin and LeResche in 1992 provided an important first step towards an etiology-based system.This symptom-based system provides well-defined operational definitions to distinguish TMD cases from controls, as well as to diagnose specific TMD subtypes.

The RDC/TMD has been used in many epidemiologic and clinical studies of TMDs. The aim of the present study was to assess the knowledge and awareness among dental practitioners about the RDC/TMD.

Materials and Methods

The Research Diagnostic Criteria (RDC) categorise TMD criteria into 3 groups according to the common factors among conditions. TMD’s RDC groups are:

GROUP I: Muscle disorders:

I.a Myofascial pain
I.b Myofascial pain with limited opening

GROUP II: Disc Displacements (DD):

II.a DD with reduction
II.b DD without reduction with limited opening
II.c DD without reduction without limited opening

GROUP III: Other common Joint disorders:

III.a Arthralgia
III.b Osteoarthritis
III.c Osteoarthrosis

A subject can be allocated a maximum of one muscle disorder. In addition, only one diagnosis from each group (II and III) can be assigned to each joint. Therefore, at one time, a number of diagnoses can be given to one person widely ranging from 0 (no TMD diagnosis) up to 5. However, to assign more than 3 diagnoses to one patient,is uncommon [18]. A well-structured multiple choice based structured questionnaire was framed. It was circulated, by electronic media, to the dentists involved in clinical practice.

The sample size was chosen by simple randomised sampling as 100 clinicians practicing in Chennai, from the data obtained on all current practitioners in the city. Demographic data of gender and the designation of the dental clinicians were taken. Personal information was not taken to avoid bias in the survey.

The questionnaire was circulated to around 150 clinicians and 100 participants answered the survey. The questionnaire was circulated to all participants including, postgraduate students, staffs in institutions, private practitioners and results were tabulated. A total of 5 questions were formulated based on the awareness of RDC/TMD for diagnosis of TMD [Tabe 1].

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Table 1:

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Table 1. Table showing the questionnaire included in the survey.

Results

Among the participants of the survey conducted, 82.1% were female and 17.9% were male dental clinicians. The participants of survey included 22.7% practitioners in private clinic, 50% postgraduate students, 18.2% students in their internship, and 9.1% undergraduate students [Figure 2]. The data acquired from this survey exhibited that 72.7% of dentists were aware, while 27.3% were unfamiliar about the RDC/TMD [Figure 3]. Around 88.1% dentists were familiar with the bimanual technique of palpation of TMJ while 11.9% of them were unaware about the same [Figure 4]. Among the participants of this survey, 68.7% dentists encountered cases with TMD and 31.3% did not come across such cases in routine practice [Figure 5]. Ony 24.6% the population studied, used the RDC/TMD for diagnostic criteria to suspect any TMD, while the rest 75.4% did not [Figure 6]. If TMD was suspected, 88.1% of the participants studied, referred the patient for a thorough radiographic investigation whereas 11.9% failed to refer.

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Figure 1:

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Figure 1. Designation of the participants of the survey.

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Figure 2:

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Figure 2. Awareness about the RDC criteria.

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Figure 3:

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Figure 3. Awareness about the bimanual palpation technique.

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Figure 4. Number of TMD cases in the clinic.

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Figure 5:

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Figure 5. Using RDC for TMD diagnosis.

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Figure 6:

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Figure 6. Suspected patients sent for radiographic investigation.

Discussion

This survey highlights the awareness of dental clinicians about TMD and its diagnosis in specific.Among the population studied, 75.4% dentists did not use RDC/TMD for diagnosis of TMD. Although this tool is the 'gold standard', the Research Diagnostic Criteria for TMD (RDC/TMD) is rarely used in general practice. [19]. The results of this survey emphasises the need for enhancing awareness among dental clinicians regarding the use of protocols for diagnosis for TMD.

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 ambiguity. Tegelberg et al., [5] found that many dentists lacked routines for making diagnoses and only 25-50% of dentists reported positive experiences in relation to TMD diagnosis and management [20]. Another study found that a fear of misdiagnosing TMD, was common among general dental practitioners and hence often these patients were referred to specialist centres or hospital setting [21].
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) [22].

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/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 [23]. The RDC/TMD remains the gold standard for use in research [19].

In future, studies can also be done to determine if other simplified versions of the RDC/TMD's clinical examination, similar to the Clinical Examination Protocol-TMD (CEP-TMD), would have validity but be quicker to carry out than RDC/TMD.

Conclusion

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. 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.

The results of this survey accentuates the need for dental clinicians, worldwide, to use the standard protocols for diagnosis for TMD. This will aid in scrutinizing any suspected TMD cases and avoid negligence of the existing underlying disease.