Received: 25 January 2021 | Accepted: 25 February 2021

DOI: 10.1111/joor.13175

ORIGINAL ARTICLE

Diagnostic criteria for temporomandibular disorders (DC/TMD)

for children and adolescents: An international Delphi study—­
Part 1-­Development of Axis I

Roberto Rongo1 | EwaCarin Ekberg2 | Ing-­Marie Nilsson2,3 | Amal Al-­Khotani4,5 |

Per Alstergren2,4,6 | Paulo Cesar Rodrigues Conti7,8 | Justin Durham9,10 |
Jean-­Paul Goulet11 | Christian Hirsch12 | Stanimira I. Kalaykova13 | Flavia P. Kapos14 |
Osamu Komiyama15 | Michail Koutris16 | Thomas List2,4 | Frank Lobbezoo16 |
17 18 19
Richard Ohrbach | Christopher C. Peck | Claudia Restrepo |
20 2,17 2,4,6,21
Maria Joao Rodrigues | Sonia Sharma | Peter Svensson |
16 22 1
Corine M. Visscher | Kerstin Wahlund | Ambra Michelotti
1
Department of Neurosciences, Reproductive Sciences and Oral Sciences, School of Orthodontics, University of Naples Federico II, Naples, Italy
2
Department of Orofacial Pain and Jaw Function, Faculty of Odontology, Malmö University, Malmö, Sweden
3
Center for Oral Rehabilitation, FTV Östergötland, Norrköping, Sweden
4
Scandinavian Center for Orofacial Neurosciences, Sweden
5
East Jeddah Hospital, Ministry of Health, Jeddah, Saudi Arabia
6
Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden
7
Department of Prosthodontics and Periodontology, Bauru School of Dentistry –­University of São Paulo, Bauru, Brazil
8
Bauru Orofacial Pain Group, University of São Paulo, Bauru, Brazil
9
School of Dental Sciences, Newcastle University, Newcastle Upon Tyne, UK
10
Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
11
Faculty of Dental Medicine, Laval University, Quebec, QC, Canada
12
Clinic of Pediatric Dentistry, University of Leipzig, Leipzig, Germany
13
Department of Oral Function and Prosthetic Dentistry, College of Dental Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
14
Department of Epidemiology, University of Washington, Seattle, WA, USA
15
Division of Oral Function and Rehabilitation, Nihon University School of Dentistry at Matsudo, Matsudo, Japan
16
Department of Orofacial pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA, University of Amsterdam and Vrije Universiteit
Amsterdam, Amsterdam, The Netherlands
17
Department of Oral Diagnostic Sciences, University at Buffalo, Buffalo, NY, USA
18
Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
19
CES-­LPH Research Group, Universidad CES, Medellin, Colombia
20
Institute for Occlusion and Orofacial Pain Faculty of Medicine, University of Coimbra, Coimbra, Portugal
21
Section of Orofacial Pain and Jaw Function, School of Dentistry and Oral Health, Aarhus, Denmark
22
Department of Stomatognathic Physiology, Kalmar County Hospital, Kalmar, Sweden

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2021 2021 The Authors. Journal of Oral Rehabilitation published by John Wiley & Sons Ltd

836 | 
wileyonlinelibrary.com/journal/joor J Oral Rehabil. 2021;48:836–845.
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RONGO et al. 837

Correspondence
Roberto Rongo, Department of Abstract
Neuroscience, Reproductive Sciences Background: Since in children and adolescence prevalence is assessed mainly on self-­
and Oral Sciences –­University of Naples
‘Federico II’, Via Pansini 5, 80131 Naples, reported or proxy-­reported signs and symptoms; there is a need to develop a more
Italy. comprehensive standardised process for the collection of clinical information and the
Emails: [email protected] and
[email protected] diagnosis of TMD in these populations.
Objective: To develop new instruments and to adapt the diagnostic criteria for tem-
poromandibular disorders (DC/TMD) for the evaluation of TMD in children and
adolescents.
Method: A modified Delphi method was used to seek international consensus among
TMD experts. Fourteen clinicians and researchers in the field of oro-­facial pain and
TMD worldwide were invited to participate in a workshop initiated by the International
Network for Orofacial Pain and Related Disorders Methodology (INfORM scientific
network) at the General Session of the International Association for Dental Research
(IADR, London 2018), as the first step in the Delphi process. Participants discussed
the protocols required to make physical diagnoses included in the Axis I of the DC/
TMD. Thereafter, nine experts in the field were added, and the first Delphi round was
created. This survey included 60 statements for Axis I, and the experts were asked to
respond to each statement on a five-­item Likert scale ranging from ‘Strongly disagree’
to ‘Strongly agree’. Consensus level was set at 80% agreement for the first round, and
at 70% for the next.
Results: After three rounds of the Delphi process, a consensus among TMD experts
was achieved and two adapted DC/TMD protocols for Axis I physical diagnoses for
children and adolescents were developed.
Conclusion: Through international consensus among TMD experts, this study adapted
the Axis I of the DC/TMD for use in evaluating TMD in children and adolescents.

KEYWORDS

adolescents, children, Delphi study, diagnostic criteria, temporomandibular disorders

1 | I NTRO D U C TI O N for females.7,8 However, in children under the age of 10 prevalence is

assessed mainly on self-­reported or proxy-­reported signs and symp-
Temporomandibular disorders (TMDs) are a group of musculoskel- toms; hence, there is a need to develop a more comprehensive stan-
etal disorders that involve the temporomandibular joints (TMJs), dardised process for the collection of clinical information and the
masticatory muscles and associated tissues or structures.1 TMDs diagnosis of TMD in children and adolescents, so that reliability and
are a significant public health problem with a prevalence in adults validity can be assessed and improved for this population.16
of 5%–­30% according to different pathologies, different age range Since 2014, the international standard for the assessment of
and different assessment forms. 2–­4 Reported TMD prevalence in TMDs is the Diagnostic Criteria for TMD (DC/TMD).1 The DC/TMD
children and adolescents varies widely in the literature from 4.2% consists of two axes and their respective instruments: Axis I for
to 68%, depending on population and method of assessment.5–­9 physical diagnoses and Axis II for assessment of psychosocial sta-
Painful and dysfunctional TMD might be associated with emotional tus and pain-­related disability. The DC/TMD is validated for several
stress, depression, sleep and hormonal disturbances, and functional diagnoses as based on a standardised assessment protocol including
complications.10–­12 In turn, the patient's daily life will be adversely history and clinical examination. A diagnostic algorithm utilising both
affected by the presence of a TMD; in addition, TMDs result in in- history and clinical data permits to have very high sensitivity and
creased pursuit of medical care which consumes both time and specificity for some TMD subgroups and consequently excellent di-
money.13 TMDs are a considerable health problem in children and agnostic accuracy for TMD in adults.1
adolescents; several studies consistently show that TMD prevalence The DC/TMD is validated for individuals who are 18 or more years
increases with age from childhood to adolescence,7–­9,14,15 especially of age; consequently, using the DC/TMD in children and adolescents
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838 RONGO et al.

TA B L E 1 List of experts included in the Delphi study with area of expertise and affiliations

Name surname Area of expertise Affiliations

1. Al-­Khotani Amal TMD/Oro-­facial Pain in children and adolescents; Paediatric Ministry of Health (Saudi Arabia)
Dentistry; Paediatric Psychology, Epidemiology
2. Alstergren Pera TMD/Oro-­facial Pain; Rheumatological disease; TMJ Malmö University (Sweden)
physiology
3. Durham Justina TMD/Oro-­facial Pain; TMD pathophysiology; TMD treatment Newcastle University (United
Kingdom)
4. Ekberg EwaCarina TMD/Oro-­facial Pain; TMD pathophysiology; TMD treatment Malmö University (Sweden)
5. Goulet Jean-­Paul TMD/Oro-­facial Pain; TMD treatment; Oral disease Laval University (Canada)
6. Hirsch Christian Epidemiology; TMD/Oro-­facial Pain in children and University of Leipzig (Germany)
adolescents; TMD treatment
7. Kalaykova Stanimira I.a TMD/Oro-­facial pain; Dental Sleep Disorders; Oral physiology Radboud University Medical
Centre (The Netherlands)
8. Kapos Flavia P.a TMD/Oro-­facial Pain; Epidemiology; TMD diagnosis University of Washington (United
States of America)
9. Komiyama Osamu TMD/Oro-­facial Pain; TMD pathophysiology; TMD treatment Nihon University (Japan)
10. Koutris Michaila TMD/Oro-­facial pain; Dental Sleep Disorders; TMD ACTA (The Netherlands)
pathophysiology
11. List Thomasa TMD/Oro-­facial Pain; Oral physiology; TMD treatment Malmö University (Sweden)
12. Lobbezoo Frank TMD/Oro-­facial Pain; Oral Movement Disorders; Dental Sleep ACTA (The Netherlands)
Disorders
13. Michelotti Ambraa TMD/Oro-­facial Pain; TMD treatment; Orthodontics University of Naples Federico II
(Italy)
14. Nilsson Ing-­Mariea Epidemiology; TMD/Oro-­facial Pain in children and Malmö University (Sweden)
adolescents; TMD treatment
15. Ohrbach Richarda TMD/Oro-­facial Pain; Psychology; Epidemiology University of Buffalo (United States
of America)
16. Peck Christopher C.a TMD/Oro-­facial Pain; TMD treatment; Neuroscience University of Sydney (Australia)
a
17. Restrepo Claudia TMD/Oro-­facial Pain in children and adolescents; Paediatric Universidad CES (Colombia)
Dentistry; Dental Sleep Disorders
18. Rodrigues Conti Paulo Cesar TMD/Oro-­facial Pain; TMD diagnosis; TMD treatment Universidade de São Paulo (Brazil)
19. Rodrigues Maria Joaoa TMD/Oro-­facial Pain; Dental Sleep Disorders; TMD treatment University of Coimbra (Portugal)
20. Sharma Soniaa TMD/Oro-­facial Pain; Epidemiology; TMD diagnosis University of Buffalo (United States
of America)
21. Svensson Peter TMD/Oro-­facial pain; Neuroscience; Oral physiology Aarhus University (Denmark)
22. Visscher Corine M. TMD/Oro-­facial pain; Physiotherapy; Dental Sleep Disorders ACTA (The Netherlands)
23. Wahlund Kerstin Epidemiology; TMD/Oro-­facial Pain in children and Malmö University (Sweden)
adolescents; TMD treatment
a
Experts that participated in the workshop in London 2018.

requires a form of adaptation for each age group.1 Adaptation of the an effective method moving towards testable hypotheses.19 One of
DC/TMD includes (1) a separate language review for both question- the methods used for decision-­making among experts is the Delphi
naires and clinical examination, due to the difference in understand- method. This method includes a series of questions and statements
ing and speaking skills between adults, adolescents and children,17 that are regrouped in different ‘rounds’ and thereby presents several
and (2) modified protocols for clinical assessment. Adaptation and advantages over other consensus techniques: it is anonymous and
assessment of content and construct validity of the Spanish transla- there is less possibility that some experts may influence the opinions of
tion of the DC/TMD Axis I were performed in 7-­ to 11-­year-­old chil- other experts as they might in a face-­to-­face setting.20 Moreover, as it
dren in Colombia, finding high internal consistency (.72 ≤ Cronbach's is usually performed online, experts from different geographic regions
18
alpha ≤ .94). can easily be included. The Delphi method is well recognised as legiti-
In the development or adaptation of diagnostic systems for which mate and suitable for addressing highly complex problems, such as the
high-­quality evidence is not yet available, relying on experience of development of a new diagnostic instrument, and as being flexible and
international experts in the field to achieve consensus on a topic is adaptable to different research contexts and data collection.21
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RONGO et al. 839

FIGURE 1 Flow chart of Delphi rounds

The aim of this study was to develop new instruments to diag- demographics, screening, health, Symptom Questionnaire, clinical ex-
nose TMDs in children and in adolescents by the adaptation of DC/ amination, imaging, and diagnosis as presented in the DC/TMD.
TMD Axis I through an international Delphi study with a consensus Twenty-­three experts worldwide (Table 1) were invited by e-mail
among TMD experts. This paper is focused on the Delphi process re- to participate in the Delphi process; this included 14 experts who
lated to the DC/TMD Axis I, while the Delphi process related to the had previously participated in the workshop in London (exclud-
DC/TMD Axis II and the full examination protocols of the DC/TMD ing the facilitator RR) and a further 9 experts who were identified
for children and adolescents will be described in future publications. among different competences, such as surgeons, orthodontists,
oro-­facial pain specialists, paediatric dentists, physiotherapists, psy-
chologists and epidemiologists; 100% of the invited experts agreed
2 | M ATE R I A L S A N D M E TH O DS to participate. An expert was defined as a person with at least five
years of experience in the clinical management of TMD patients,
The modified Delphi method was used to seek international consen- experience in using the DC/TMD and research interest in TMDs
sus for Axis I assessment among TMD experts.22 Development of based on publications in international peer-­reviewed journals. The
the adaptations of the DC/TMD started at a workshop promoted by experts were asked to answer each statement on a five-­item Likert
the International Network for Orofacial Pain and Related Disorders scale ranging from ‘Strongly disagree’ to ‘Strongly agree’. In addition,
Methodology (INfORM) at the General Session of the International comments could be provided for each statement. Agreement on
Association of Dental Research in London in 2018. Fourteen TMD ex- each statement was reached if the sum of experts replying ‘Agree or
perts (RO, SS, FK, CR, MJR, JD, MK, SK, AM, TL, PA, ECE, IMN, CP) and Strongly agree’ or the sum of experts replying ‘Disagree or Strongly
the Delphi facilitator (RR) participated in the meeting and created a list disagree’ was equal to or higher than the selected threshold for each
of key issues, related to the applicability of DC/TMD for children and round. Threshold level for consensus was set at 80% agreement (18
adolescents. After this workshop, the facilitator (RR), who did not par- out of 23) for the first round and at 70% (16 out of 23) for the next
ticipate in the online Delphi survey, constructed a survey of 60 state- rounds. 23,24 The Survey Monkey® cloud-­based software (SVMK)
ments based on the key issues pertaining to physical diagnoses (Axis I) was used to develop the online survey. Together with the invitation
as outlined by the experts. Each of these statements was subsequently to participate in the survey, each expert received a letter of instruc-
assessed during the Delphi online survey. The statements addressed tions and a list of references with full-­text versions of all the papers.
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840 RONGO et al.

The Delphi process is shown in Figure 1; after Delphi round-­1, TA B L E 2 Round of agreement achievement
the facilitator and the organising committee (ECE, IMN, AM) eval-
Round Round Round No
uated the results. Based on comments from the experts, existing 1 2 3 agreement
statements were either rephrased or removed or new statements
Structure
were added, resulting in a total of 26 statements for Delphi round-­2.
Age x
A similar process of evaluating the experts’ replies and comments
Short and x
was used at the second round which led to 15 statements for Delphi
Complete Forms
round-­3. Evaluation of the replies and data analysis was performed
History
blinded; that is, the organising committee (ECE, IMN, AM) did not
Screening x
know the experts’ panels identities. At the end of each round, the ex-
Demographics, x
perts received a document with the instructions for the next round
health
and a summary of the previous round's evaluation. Only the facilita- questionnaire,
tor (RR) kept the code list to match responses to the experts’ identi- Symptom
ties. Final consensus was achieved in November 2019. The present Questionnaire

manuscript was sent to all the TMD experts who were invited to be Clinical examination
co-­authors, and the manuscript was finalised in September 2020. Mandatory x
commands
Jaw opening x
3 | R E S U LT S Jaw lateral and xa
protrusive
excursions
The results of the three Delphi rounds are shown in Table 2. The
Sounds during jaw x
response rate was 100%; that is, all experts responded to all state-
opening
ments in each of the three rounds.
Sounds during xa
Delphi round-­1 resulted in 45% (27 out of the 60 statements)
jaw lateral and
agreement among the experts. Of the remaining 33 statements that protrusive
did not achieve consensus at Delphi round-­1, 12 statements were excursions
excluded, 4 were retained as-­is, 17 were rephrased based on ex- Muscular and joint x
perts’ answers and comments, and 5 new statements were added, palpation

for a total of 26 statements presented at round-­2. In the Delphi Referred pain xa

round-­2, 11 out of 26 statements (42%) reached the 70% agreement. Familiar pain x
Out of the 15 statements not reaching consensus, 8 were rephrased, Imaging
6 were excluded, 1 was retained as-­is, and 6 new statements were Imaging x
added according to the experts’ comments to create a survey of 15 a
Agreement achieved only in adolescents.
statements presented at round-­3. Finally, in the Delphi round-­3, 7
out of 15 statements (47%) reached the 70% consensus. Out of the 8
statements not reaching consensus, 1 statement with clear disagree- adolescents. There was agreement to use the 3Q/TMD question-
ment was excluded, and 7 statements, albeit with a trend towards naire25 as an instrument for TMD screening in both age groups.
agreement, failed to achieve consensus (Figure 1). Finally, the clinical diagnostic classification already present in the
DC/TMD was retained.

3.1 | Demographics, screening, health and Symptom

Questionnaire 3.2 | Clinical examination

During the Delphi survey, experts agreed to define adolescents from The experts agreed not to use the mandatory commands for the
10 years of age or older. Participants agreed to create two different clinical examination such as used in the adult version of the instru-
Axis I protocols: one for children and one for adolescents. For each ment but sought to provide instructions for the clinician to explain
of the child and adolescent DC/TMD protocols, consensus indicated the concepts included in the DC/TMD.
that both a short version for screening and a comprehensive version
needed to be created. There was agreement among the experts to
include three general health questionnaires: one for children, one 3.2.1 | Adolescents
for adolescents and one for their parents, two demographic ques-
tionnaires one for children and one for adolescents, and a rephrased Experts agreed to maintain the examination of jaw movements
form of the Symptom Questionnaire, each adapted for children and (opening, closing, protrusion and laterotrusion) including the report
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RONGO et al. 841

of pain on movement, as it is used in the protocol in the adult version, TMD diagnostic protocol in order to be adopted for use in children
using cut-­off measurements for limited opening already present in and in adolescents.
the literature (≤36 mm, 3rd percentile at 10 years of age). 26 Muscle
and joint palpation pain and the evaluation of joint noises were not
modified with respect to the adult version. Indeed, regarding the 4.1 | Demographics, screening, health and Symptom
muscle and TMJ pain assessment, the experts agreed to maintain Questionnaire
both the 30-­day time frame as the default period for symptoms rel-
evant to the diagnosis and the amount of pressure as recommended Adolescents were defined from 10 years of age or older, according
by the DC/TMD for adult, and they agreed to ask for familiar and to the World Health Organization (WHO) definition. 27 However, the
referred pain. Agreement was also achieved among experts to main- ability of the individual to understand and respond to the questions is
tain the examination of joint noises during all mandibular move- not related only to age. Hence, for individuals transitioning between
ments, as it is in the DC/TMD for adults. childhood and adolescence, the child or adolescent assessment pro-
tocol should be selected depending on the patients’ cognitive devel-
opment. Children's cognitive development shows four main stages:
3.2.2 | Children sensorimotor period (birth-­2 years of age), preoperational period
(2–­7 years old), concrete operational period (7 years old-­puberty),
Experts agreed only to maintain the examination of jaw opening and formal operations (puberty to adulthood), and although the stages
closing movements, including pain on movement, as it is in the DC/ are sequential, their time frame is flexible. 28,29 The identification
TMD for adults, using cut-­off measurements for limited opening of children's cognitive development may be possible through spe-
(≤32 mm, 3rd percentile at 6 years of age). 26 No agreement, how- cific tests such as the Differential Ability Scales-­II (DAS-­II)30 or the
ever, was obtained in retaining or not the assessment of lateral and Kaufman Assessment Battery for Children (KABC),31 but these tools
protrusive movements. would increase the time burden of the consultation (around 60 min-
Regarding muscle and joint palpation, the recommendations utes to complete the test). Therefore, in research setting the DC/
for children were to assess muscle pain by palpation of the mas- TMD for children should be used in subjects <10 years old, while
seter and temporalis at three sites instead of nine with the usual the DC/TMD for adolescent in subjects ≥10 years old. In a clinical
2
recommended load of 1 kg/cm . Palpation of supplementary mas- setting, the clinician may be able to grossly identify the cognitive
ticatory muscles was considered optional. The TMJ palpation was level of the child during the anamnesis and then select the assess-
kept as it is in the adult version. However, while there was consen- ment protocol.
sus in asking for familiar pain in children, the threshold of the 70% The general health questionnaire, demographic questionnaire
of agreement was not achieved on whether or not to include the and Symptom Questionnaire should be modified for children and
assessment of referred pain, and what should be considered the adolescents from the DC/TMD protocol. Furthermore, the ex-
correct time frame to identify familiar pain in children. Finally, the perts agreed to add a general health questionnaire for the parents.
experts agreed to evaluate joint noises during opening and clos- Parents’ health is an important factor for children with acute mus-
ing movements, but there was not consensus on considering as culoskeletal pain; more specifically, chronic pain in parents might
supplementary the joint noise assessments during the lateral and be a predictor of children's pain intensity and activity limitations
protrusive movements. related to pain. 32
As with the DC/TMD for adults, there was agreement in devel-
oping both a short and a comprehensive version for each of children
3.3 | Imaging and for adolescents, allowing an initial screening evaluation that
might be followed by a comprehensive assessment.1 The short ver-
The experts agreed on considering imaging as a supplementary test sion would be intended for routine use not only by general dentists
in selected cases, such as those with no clear diagnosis, needing con- but also by other specialists outside the field of dentistry, in order to
firmation of a diagnosis, or with a differential diagnosis. promote early diagnosis (paediatricians, rheumatologist, etc.)
As screening questionnaires, the TMD pain screener33 and the
3Q/TMD questionnaire were considered. 25 The experts agreed to
4 | D I S CU S S I O N choose the 3Q/TMD, which includes three questions: two on pain
and one on function. The choice was supported by validation of the
In light of the prevalence of TMD in children and adolescents, two pain questions in a Swedish sample of adolescents,34 and that
the aim of this Delphi study was to collect and organise expert the 3Q/TMD included one other question that assesses jaw func-
opinions to develop a standardised protocol for TMD diagnosis in tion. In addition, because the Symptom Questionnaire already in-
children and adolescents by adapting the pre-­existing DC/TMD cludes the TMD pain screener items, there is no real shortcoming
for adults. The Delphi method was used to reach a consensus in adopting the 3Q/TMD screener for children and adolescents.
among TMD experts regarding the changes needed in the DC/ The INfORM research agenda encourages the assessment of the
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842 RONGO et al.

reliability and validity of the 3Q/TMD in a child and adolescent pop- defined as ‘pain present outside the boundaries of the assessed tis-
ulation by its members in their respective institutions. sue’ and is evaluated by maintaining a steady palpation pressure for
five seconds, before asking patients about pain spreading/referral.
Provoked TMD pain might refer to another anatomical area such as
4.2 | Clinical examination the teeth or neck; hence, this evaluation helps to identify the correct
source of pain.1
The need to use mandatory commands was much discussed among
the experts. Mandatory commands are structured verbal instruc-
tions given to the patients prior to and during performing the clinical 4.2.2 | Children
examination in order to promote maximal reliability. However, the
use of mandatory commands represents a high barrier in the imple- The experts agreed to keep the opening and closing examination
mentation of the DC/TMD in daily general practice.35 A recent study for children as it is in the adult version, but there was no agree-
demonstrated that not using mandatory commands did not affect ment for measuring lateral and protrusive movements. Indeed,
the diagnostic reliability of pain-­related TMD in Swedish adults in a 65% of the experts (15 out of 23) disagreed on the need to assess
general dentistry setting.35 Therefore, the experts’ final suggestion mandibular excursions in children due to the difficulty in inten-
was to eliminate the mandatory commands and to provide a list of tionally performing such movements and the low reliability. The
procedural instructions to the examiner, explaining the examination committee decided to retain lateral and protrusive movements in
process and the intent of each command in detail. In this way, the the clinical examination to evaluate the usefulness of such param-
examiner could understand the concepts and the intention behind eters in future research protocols. There was agreement to assess
each procedure and then use his/her own words with the child or joint noises during the opening and closing movements, while 65%
adolescent patient in a manner that would be tailored to that indi- of the experts disagreed with noises assessment during laterotru-
vidual and presumably easy to comprehend. sion and protrusion. The lack of agreement was due to the poor
reliability and the low prevalence of clicking in laterotrusion in
children. Nonetheless, the committee recommends assessing joint
4.2.1 | Adolescents noises during lateral and protrusive movements while waiting for
diagnostic accuracy data in the future. Regarding the muscular
For the adolescent population, assessment of the range and pain on palpation in children, the experts agreed to modify the DC/TMD
movements (opening, closing, laterotrusion and protrusion) was re- protocol. Due to the small size of masseter and temporalis mus-
tained as it is in the DC/TMD for adults. Albeit time-­consuming, in cle, and to reduce clinical examination time, the experts agreed
adults this part of the clinical examination provides additional infor- to palpate only three points per muscle, one for each area (ante-
mation, useful in the diagnosis of pain-­related TMD.1 The experts rior, middle, posterior bellies for the temporalis, and origin, body,
agreed to add cut-­off measurements for limited opening according and insertion for the masseter). The time and the load needed to
to data reported in the literature with a lower threshold of 36 mm perform the palpation were otherwise retained as in the recom-
26
that represents the 3rd percentiles at 10 years of age. mendation for adults. Although agreement was reached on ask-
The experts agreed to keep the assessment of joint noises to ing for familiar pain, the experts did not agree on the time frame
identify displacement or degenerative TMD as it is in the DC/TMD. related to familiar pain in children. Time perception in children is
Palpation of the masseter, temporalis and the TMJ were main- different compared to that of adults: until the age of 10 children do
tained as it is in the DC/TMD version for adults, asking for famil- not spontaneously use explicit timing-­related strategies, and the
iar pain and for referred pain when there is a need to discriminate first step in the acquisition of time knowledge is completed after
among the sub-­t ypes of myalgia. For the masticatory muscles, 12 years old. 36–­39 Hence, the use of a time frame related to familiar
masseter and temporalis, a nine-­point palpation sequence was pain could be complicated or misleading in those ages. Since no
confirmed, and the same palpation procedure of the DC/TMD for agreement was reached, the 30-­day time frame was retained to
adults was also suggested for the TMJ lateral pole and around the be tested in future studies. However, it must be considered that
pole. During the palpation examination, the load exerted for mus- a very recent study, published after the end of the Delphi pro-
cular palpation and around the pole must be maintained from two cess, tried a 15-­day time frame in the assessment of the Symptom
2
up to five seconds with an intensity of 1 kg/cm in order to evalu- Questionnaire and in the clinical examination of DC/TMD Axis I
ate for referred pain, while the same time but with load of 0.5 kg/ and found better accuracy compared to the 30-­day time frame
cm2 is retained for lateral pole palpation. During palpation, patients in children between 7 and 11 years.18 Future studies comparing
should be asked for familiar pain and referred pain. Familiar pain is the 30-­day time frame and the 15-­day time frame should be con-
defined as ‘pain that is like or similar to the pain that the patient has ducted on this population to further support this hypothesis; in ad-
been experiencing in the last 30 days’.1 This concept was found to dition, the role of parent information should be considered. Finally,
be fundamental for improving sensitivity and specificity for TMD di- agreement regarding the assessment of referred pain in children
agnosis and in particular minimising false positives. Referred pain is was not achieved. Referred pain was considered by the experts
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13652842, 2021, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/joor.13175 by Cochrane Chile, Wiley Online Library on [02/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
RONGO et al. 843

as a complex concept to understand and, as far as we know today, or overestimating the importance of some aspects due to personal
does not guide the choice, or change in the management strategy. opinions.
On the other hand, it might be very important to determine pos- To complete DC/TMD Axis I for children and adolescents, three
sible severity of pain and possible syndromes associated with such rounds were necessary, and the level of agreement was set for the
pain. Considering the lack of agreement achieved, the committee Delphi round-­1 at 80% and for the Delphi round-­2 and round-­3 at
decided to test the comprehension of the referred pain by children 70%. There is not a defined cut-­off for agreement in Delphi studies
during future studies. (51%,45 70%23 or 80%24); on the other hand, it has been shown that
changing the cut-­off from 80% to 70% does not influence the re-
sults if new questions are proposed.46 The Delphi was stopped after
4.3 | Imaging three rounds because it was clear, after the analysis of comments
from the participants, that some points concerning children's clinical
Experts agreed that imaging such as magnetic resonance imaging examination needed to be tested through a content and criterion
and/or computed tomography (cone beam or axial) should be per- validation study.
formed only when needed. Because children and adolescents are The construction of the DC/TMD for adolescents and for chil-
still growing, some TMDs, even if less common, should be consid- dren also needs the development and adaptation of the instruments
ered very important in this population. For example, TMJ mani- to evaluate psychosocial status and pain-­related disability (Axis II).
festations of juvenile idiopathic arthritis,40 idiopathic condylar For the assessment of Axis II, the DC/TMD includes questionnaires
resorption or osseous ankylosis that are present in the expanded that evaluate jaw function and oral behaviours, and that screen for
taxonomy of the DC/TMD, are related to growth disturbances and depression, anxiety and other comorbidities. In order to have a wide
may have severe consequences in children.40–­4 3 For most of diag- information on psychological aspects, the committee decided to
noses included in the expanded taxonomy, there is still not a high also include experts in psychosocial disciplines and to create a new
diagnostic performance of the clinical examination; hence, imag- Delphi study. This new Delphi comprising world experts in psycho-
ing can help in better identifying these pathologies. Therefore, the logical constructs for children and adolescents and oro-­facial pain
role of the imaging becomes fundamental in cases of unclear diag- experts aims to adapt the Axis II of the DC/TMD for adults, and the
nosis or to generate information able to influence the treatment results of this Delphi process will be presented in future publications.
plan, or to follow up the patient.

5 | CO N C LU S I O N S A N D FU T U R E
4.4 | Delphi study design D I R EC TI O N S

The modified Delphi process enabled the creation of expert con- Thanks to this Delphi study, experts developed new instruments
sensus in setting up new evaluation protocols for the diagnosis of that aim to assess physical diagnoses (Axis I) of TMDs in children and
TMD in children and adolescents. 22 The classical Delphi is a use- in adolescents, by modifying the DC/TMD for adults. The developed
ful forecasting tool based on iterative sequential individual expert instruments need to be validated.
input, and in the modified Delphi groups of experts are called to To complete the creation of DC/TMD for children and DC/TMD
make decisions simultaneously. 22 The Delphi group consisted of for adolescents, a new Delphi study was conducted for the develop-
23 international experts from Europe, North and South America, ment of instruments to evaluate the psychosocial status and pain-­
Asia and Oceania. The wide dissemination of the DC/TMD for related disability within DC/TMD Axis II, that will be presented in a
adults through the translation into almost 20 languages made this separate paper.
project possible. Once that both axes were adapted for children and adolescents,
The ideal number of experts that should be included in a Delphi other papers will describe the short and comprehensive form of the
process is not established. In planning this kind of study, there is child DC/TMD and adolescent DC/TMD, including the developed
a delicate balance between the amount of information that a large instruments.
number of participants might produce and the difficulty in analysing
data and reaching agreement. In this study, 23 world experts were C O N FL I C T O F I N T E R E S T
included, representing professionals involved in TMD diagnosis and The authors declare that they have no conflict of interest.
treatment, who provided global perspectives on what can be consid-
ered useful for TMD diagnosis.44 This Delphi process started with AU T H O R C O N T R I B U T I O N
a face-­to-­face meeting involving 14 of the 23 who were invited in RR, ECE, IMN, AM Conception and design of study; RR, ECE, IMN,
London to create a list of key issues, related to the applicability of AM Acquisition of data; RR, ECE, IMN, AM Data analysis and/or in-
DC/TMD for children/adolescents, to be used by the facilitator to terpretation; AAK, PCRC, JPG, CH, OK, FL, PS, CMV, KW, RO, SS,
develop the survey. This approach allowed the facilitator to create a FK, CR, MJR, JD, MK, SK, AM, TL, PA, ECE, IMN, CP, RR Drafting of
survey based on the experts’ suggestions, avoiding underestimating manuscript and/or critical revision AAK, PCRC, JPG, CH, OK, FL, PS,
 |

13652842, 2021, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/joor.13175 by Cochrane Chile, Wiley Online Library on [02/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
844 RONGO et al.

CMV, KW, RO, SS, FK, CR, MJR, JD, MK, SK, AM, TL, PA, ECE, IMN, 11. Clemente M, Lourenço S, Coimbra D, Silva A, Gabriel J, Pinho J.
Three-­dimensional analysis of the cranio-­cervico-­mandibular
CP, RR Approval of final version of manuscript.
complex during piano performance. Med Probl Perform Art.
2014;29:150-­154.
DATA AVA I L A B I L I T Y S TAT E M E N T 12. Suvinen TI, Reade PC, Kemppainen P, Könönen M, Dworkin SF.
The data that support the findings of this study are available from Review of aetiological concepts of temporomandibular pain disor-
ders: towards a biopsychosocial model for integration of physical
the corresponding author [RR], upon reasonable request.
disorder factors with psychological and psychosocial illness impact
factors. Eur J Pain. 2005;9:613-­633.
ORCID 13. Østensjø V, Moen K, Storesund T, Rosén A. Prevalence of painful
Roberto Rongo https://orcid.org/0000-0002-9741-794X temporomandibular disorders and correlation to lifestyle factors
Ing-­Marie Nilsson https://orcid.org/0000-0002-0550-8925 among adolescents in Norway. Pain Res Manag. 2017;2017:2164825.
14. Al-­Khotani A, Naimi-­Akbar A, Albadawi E, Ernberg M, Hedenberg-­
Amal Al-­Khotani https://orcid.org/0000-0001-7168-9835
Magnusson B, Christidis N. Prevalence of diagnosed temporoman-
Paulo Cesar Rodrigues Conti https://orcid. dibular disorders among Saudi Arabian children and adolescents. J
org/0000-0003-0413-4658 Headache Pain. 2016;17:41.
Flavia P. Kapos https://orcid.org/0000-0002-6224-273X 15. Marpaung C, Lobbezoo F, van Selms MKA. Temporomandibular
disorders among Dutch adolescents: prevalence and biolog-
Frank Lobbezoo https://orcid.org/0000-0001-9877-7640
ical, psychological, and social risk indicators. Pain Res Manag.
Richard Ohrbach https://orcid.org/0000-0002-9266-9734 2018;2018:5053709.
Claudia Restrepo https://orcid.org/0000-0002-0695-7562 16. Christidis N, Lindström Ndanshau E, Sandberg A, Tsilingaridis G.
Sonia Sharma https://orcid.org/0000-0002-1887-7420 Prevalence and treatment strategies regarding temporomandibular
disorders in children and adolescents-­a systematic review. J Oral
Corine M. Visscher https://orcid.org/0000-0002-4448-6781
Rehabil. 2019;46:291-­3 01.
Kerstin Wahlund https://orcid.org/0000-0003-2236-8546 17. Duke NK, Carlisle J. 10 The development of comprehension. Handb
Read Res. 2010;4:199.
REFERENCES 18. Restrepo CC, Suarez N, Moratto N, Manrique R. Content and con-
struct validity of the diagnostic criteria for temporomandibular dis-
1. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for
orders axis I for children. J Oral Rehabil. 2020;47:1-­11.
Temporomandibular Disorders (DC/TMD) for clinical and research
19. Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CF,
applications: recommendations of the international RDC/TMD
Askham J, Marteau T. Consensus development methods, and
Consortium Network* and Orofacial Pain Special Interest Group†. J
their use in clinical guideline development. Health Technol Assess.
Oral Facial Pain Headache. 2014;28:6-­27.
1998;2:1-­88.
2. Progiante P, Pattussi M, Lawrence H, Goya S, Grossi P, Grossi M.
20. Bolger F, Wright G. Improving the Delphi process: lessons from
Prevalence of temporomandibular disorders in an Adult Brazilian
social psychological research. Technol Forecast Soc Change.
Community population using the research diagnostic criteria (Axes
2011;78:1500-­1513.
I and II) for temporomandibular disorders (The Maringá Study). Int J
21. Donohoe H, Stellefson M, Tennant B. Advantages and limitations of
Prosthodont. 2015;28:600-­609.
the e-­Delphi technique: implications for health education research-
3. Iodice G, Cimino R, Vollaro S, Lobbezoo F, Michelotti A. Prevalence
ers. Am J Heal Educ. 2012;43:38-­46.
of temporomandibular disorder pain, jaw noises and oral be-
22. Rauch W. The decision Delphi. Technol Forecast Soc Change.
haviours in an adult Italian population sample. J Oral Rehabil.
1979;15:159-­169.
2019;46:691-­698.
23. Sumsion T. The Delphi technique: an adaptive research tool. Br J
4. Macfarlane TV, Glenny AM, Worthington HV. Systematic review of
Occup Ther. 1998;61:153-­156.
population-­based epidemiological studies of oro-­facial pain. J Dent.
24. Green B, Jones M, Hughes D, Williams A. Applying the Delphi tech-
2001;29:451-­467.
nique in a study of GPs’ information requirements. Health Soc Care
5. Perrotta S, Bucci R, Simeon V, Martina S, Michelotti A, Valletta R.
Community. 1999;7:198-­205.
Prevalence of malocclusion, oral parafunctions and temporoman-
25. Lövgren A, Visscher CM, Häggman-­Henrikson B, Lobbezoo F,
dibular disorder-­pain in Italian schoolchildren: an epidemiological
Marklund S, Wänman A. Validity of three screening questions (3Q/
study. J Oral Rehabil. 2019;46:611-­616.
TMD) in relation to the DC/TMD. J Oral Rehabil. 2016;43:729-­736.
6. Paduano S, Bucci R, Rongo R, Silva R, Michelotti A. Prevalence
26. Müller L, van Waes H, Langerweger C, Molinari L, Saurenmann RK.
of temporomandibular disorders and oral parafunctions in
Maximal mouth opening capacity: percentiles for healthy children
adolescents from public schools in Southern Italy. Cranio.
4–­17 years of age. Pediatr Rheumatol Online J. 2013;11:17.
2020;38(6):370-­375.
27. World Health Organization. https://www.who.int/mater​nal_child_
7. Rauch A, Schierz O, Körner A, Kiess W, Hirsch C. Prevalence of an-
adole​scent/​adole​scenc​e/en/
amnestic symptoms and clinical signs of temporomandibular disor-
28. de Ribaupierre A. Piaget’s theory of cognitive development. In:
ders in adolescents-­results of the epidemiologic LIFE Child Study. J
Wright JD, ed. International Encyclopedia of the Social & Behavioral
Oral Rehabil. 2020;47:425-­431.
Sciences (Vol. 18, 2nd ed.). Oxford: Elsevier, 2015. https://doi.
8. List T, Wahlund K, Wenneberg B, Dworkin SF. TMD in children and
org/10.1016/B978Ȑ0Ȑ08Ȑ09708​6Ȑ8.23093​Ȑ6, https://archi​ve-­
adolescents: prevalence of pain, gender differences, and perceived
ouver​te.unige.ch/unige​:90546
treatment need. J Orofac Pain. 1999;13:9-­20.
29. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontic
9. Nilsson I-­M. Reliability, validity, incidence and impact of tem-
Appliances, 6th ed. Philadelphia, PA: Elsevier Health Sciences; 2018.
porormandibular pain disorders in adolescents. Swed Dent J Suppl.
30. Farmer C, Golden C, Thurm A. Concurrent validity of the differen-
2007;183:7–­86.
tial ability scales, second edition with the Mullen Scales of Early
10. List T, Wahlund K, Larsson B. Psychosocial functioning and dental
Learning in young children with and without neurodevelopmental
factors in adolescents with temporomandibular disorders: a case–­
disorders. Child Neuropsychol. 2016;22(5):556-­569.
control study. J Orofac Pain. 2001;15:218-­227.
 |

13652842, 2021, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/joor.13175 by Cochrane Chile, Wiley Online Library on [02/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
RONGO et al. 845

31. Kaufman AS, Kaufman NL. Kaufman Assessment Battery for Children, 40. Rongo R, Alstergren P, Ammendola L, et al. Temporomandibular
2nd ed. (Service AG, ed.). Circle Pines, MN: Giunti;2004. joint damage in juvenile idiopathic arthritis: diagnostic validity of
32. Clementi MA, Faraji P, Poppert Cordts K, et al. Parent factors are diagnostic criteria for temporomandibular disorders. J Oral Rehabil.
associated with pain and activity limitations in youth with acute 2019;46:450-­459.
musculoskeletal pain. Clin J Pain. 2019;35:222-­228. 41. Peck CC, Goulet JP, Lobbezoo F, et al. Expanding the taxonomy
33. Gonzalez YM, Schiffman E, Gordon SM, et al. Development of a brief of the diagnostic criteria for temporomandibular disorders. J Oral
and effective temporomandibular disorder pain screening question- Rehabil. 2014;41:2-­23.
naire: reliability and validity. J Am Dent Assoc. 2011;142:1183-­1191. 42. Bollhalder A, Patcas R, Eichenberger M, et al. Magnetic resonance
34. Nilsson I-­M, List T, Drangsholt M. The reliability and validity of self-­ imaging followup of temporomandibular joint inflammation, defor-
reported temporomandibular disorder pain in adolescents. J Orofac mation, and mandibular growth in juvenile idiopathic arthritis pa-
Pain. 2006;20:138-­144. tients receiving systemic treatment. J Rheumatol. 2020;47:909-­916.
35. Österlund C, Berglund H, Åkerman M, et al. Diagnostic criteria for 43. Kristensen KD, Schmidt B, Stoustrup P, Pedersen TK. Idiopathic con-
temporomandibular disorders: diagnostic accuracy for general den- dylar resorptions: 3-­dimensional condylar bony deformation, signs
tistry procedure without mandatory commands regarding myalgia, and symptoms. Am J Orthod Dentofac Orthop. 2017;152:214-­223.
arthralgia and headache attributed to temporomandibular disorder. 44. Akins RB, Tolson H, Cole BR. Stability of response characteristics of
J Oral Rehabil. 2018;45:497-­503. a Delphi panel: application of bootstrap data expansion. BMC Med
36. Labrell F, Mikaeloff Y, Perdry H, Dellatolas G. Time knowledge ac- Res Methodol. 2005;5:37.
quisition in children aged 6 to 11 years and its relationship with nu- 45. McKenna HP. The Delphi technique: a worthwhile research ap-
merical skills. J Exp Child Psychol. 2016;143:1-­13. proach for nursing? J Adv Nurs. 1994;19:1221-­1225.
37. Droit-­Volet S. Time perception, emotions and mood disorders. J 46. Veugelers R, Gaakeer MI, Patka P, Huijsman R. Improving design
Physiol Paris. 2013;107:255-­264. choices in Delphi studies in medicine: the case of an exemplary phy-
38. Droit-­Volet S, Zélanti PS. Development of time sensitivity and infor- sician multi-­round panel study with 100% response. BMC Med Res
mation processing speed. PLoS One. 2013;8:e71424. Methodol. 2020;20:156.
39. Droit-­Volet S. Time perception in children: a neurodevelopmental
approach. Neuropsychologia. 2013;51:220-­234.