Received: 3 April 2022 | Revised: 24 February 2023 | Accepted: 28 April 2023

DOI: 10.1111/joor.13488

ORIGINAL ARTICLE

Diagnostic criteria for temporomandibular disorders—­INfORM

recommendations: Comprehensive and short-­form adaptations
for adolescents

EwaCarin Ekberg1 | Ing-­Marie Nilsson1,2 | Ambrosina Michelotti3 |

Amal Al-­Khotani4,5 | Per Alstergren1,5,6 | Paulo Cesar Rodrigues Conti7,8 |
Justin Durham9 | Jean-­Paul Goulet10 | Christian Hirsch11 | Stanimira Kalaykova12 |
Flavia P. Kapos13,14 | Christopher D. King15,16,17 | Osamu Komiyama18 |
Michail Koutris19 | Thomas List1,5 | Frank Lobbezoo19 | Richard Ohrbach20 |
Tonya M. Palermo21 | Christopher C. Peck22 | Chris Penlington9 |
Claudia Restrepo23 | Maria Joao Rodrigues24 | Sonia Sharma1,20 | Peter Svensson25 |
Corine M. Visscher19 | Kerstin Wahlund26 | Roberto Rongo3 |
International Network for Orofacial Pain and Related Disorders Methodology (INfORM)27

Correspondence
Roberto Rongo, Department of Abstract
Neurosciences, Reproductive Sciences
Background: The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD)
and Oral Sciences–­University of Naples
“Federico II”, Via Pansini 5, 80131 Naples, for use in adults is in use worldwide. Until now, no version of this instrument for use
Italy.
in adolescents has been proposed.
Email: [email protected]
Objective: To present comprehensive and short-­form adaptations of the adult version
of DC/TMD that are appropriate for use with adolescents in clinical and research
settings.
Methods: International experts in TMDs and experts in pain psychology participated
in a Delphi process to identify ways of adapting the DC/TMD protocol for physical
and psychosocial assessment of adolescents.
Results: The proposed adaptation defines adolescence as ages 10–­19 years. Changes
in the physical diagnosis (Axis I) include (i) adapting the language of the Demographics
and the Symptom Questionnaires to be developmentally appropriate for adolescents,
(ii) adding two general health questionnaires, one for the adolescent patient and one
for their caregivers and (iii) replacing the TMD Pain Screener with the 3Q/TMD ques-
tionnaire. Changes in the psychosocial assessment (Axis II) include (i) adapting the
language of the Graded Chronic Pain Scale to be developmentally appropriate for
adolescents, (ii) adding anxiety and depression assessment that have been validated
for adolescents and (iii) adding three constructs (stress, catastrophizing and sleep dis-
orders) to assess psychosocial functioning in adolescents.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2023 The Authors. Journal of Oral Rehabilitation published by John Wiley & Sons Ltd.

J Oral Rehabil. 2023;50:1167–1180.  wileyonlinelibrary.com/journal/joor | 1167

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1168 EKBERG et al.

Conclusion: The recommended DC/TMD, including Axis I and Axis II for adolescents,
is appropriate to use in clinical and research settings. This adapted first version for
adolescents includes changes in Axis I and Axis II requiring reliability and validity test-
ing in international settings. Official translations of the comprehensive and short-­form
to different languages according to INfORM requirements will enable a worldwide
dissemination and implementation.

KEYWORDS
adolescents, diagnostic criteria, dysfunction, pain, temporomandibular disorders

1 | I NTRO D U C TI O N The RDC/TMD, the first comprehensive diagnostic system for

TMD,15 was developed for and widely used among adults in research
Temporomandibular disorders (TMDs) are a collective term for a and clinical settings. The system comprises two axes based on the
group of disorders characterised by pain, impaired function, or both biopsychosocial model of pain: Axis I for physical diagnoses and Axis
of the masticatory system and related structures. Although the field II for the assessment of psychological status and pain-­related disabil-
developed through assessment and treatment of adults, adolescents ity. Axis I has been found to have good reliability in 12–­18-­year-­old
have been found to suffer from TMDs as well. In 1999, TMD pain adolescents.16 None of the Axis II instruments, however, were val-
1
prevalence in adolescents was reported to be between 2% and 6%, idated for adolescents at that time. Hence, the orofacial pain com-
a more recent systematic review reported TMD prevalence to vary munity have used a variety of instruments to assess psychosocial
between 7% and 30% in adolescent populations when assessed with domains in adolescents.6,7,13,17–­19
the Research Diagnostic Criteria for TMD (RDC/TMD) or the sub- In 2014, the DC/TMD was published as a revision and further
sequent Diagnostic Criteria for TMD (DC/TMD). This systematic development was performed of the RDC/TMD, including validation
review found that the most common diagnoses in adolescents are of the most common diagnoses for use in the adult population. The
2
myofascial pain and disc displacement with reduction. Furthermore, DC/TMD has, so far, been translated into 21 languages in a formal
prevalence of reported TMD pain among adolescents varied from forward−backward translation process for worldwide implemen-
4% to 32% across studies using screening questions validated among tation. 20 It includes both comprehensive instruments and a sim-
3,4
adolescents. ple screener for Axis I, allowing the identification of patients that
A large population-­based study on 12–­19-­year-­old participants will likely fulfil at least one TMD diagnosis. 21 Comprehensive and
reported a higher prevalence of TMD pain in girls (6%) compared to short-­form assessments are available for Axis II. The short form of
boys (2.7%).4 Furthermore, the prevalence of TMD pain among girls assessment is useful in general dentistry, primary care and dental
showed a significant increase from 2.7% at age 12 to 7.9% at age 19. specialties other than orofacial pain.
In contrast, this increase was only moderate for boys, from 2.0% at Some of the instruments in the DC/TMD for adults have not
age 12 to 2.9% at age 19 and this gender pattern was also confirmed been validated in adolescents, since some concepts need to be de-
in a more recent study.4,5 The risk factors for onset of facial pain and velopmentally adapted for the adolescent patterns of behaviour and
TMD pain in early adolescence are female sex, somatization, number lifestyle choices. In addition, standardisation of the clinical examina-
6
of other pain complaints and life dissatisfaction, among others. tion might need to be modified to facilitate implementation. 22
TMD in adolescence is associated with emotional stress, depres- Consequently, there is a need for both short and comprehensive
sion, sleep and hormonal disturbances and functional consequenc- forms of the DC/TMD that are valid for use with adolescents. Thus, a
es.7–­9 To cope with pain, adolescents just as adults, develop various group of international experts in TMDs and pain psychology related to
pain management strategies and seek treatment to find an explana- adolescents participated in a Delphi study to identify how to adapt the
tion for the cause of their pain.10 DC/TMD for adults to the examination of adolescent populations.23,24
As adolescents with TMD, especially pain-­related TMD, com- The aim of the present article was to propose comprehensive
prise a substantial group with an obvious treatment need,11–­13 it is and short forms of the DC/TMD Axis I and Axis II that are appropri-
important to identify these patients early and to offer care to these ate for use with adolescents in clinical and research settings.
individuals in need of treatment. Since early diagnoses can influence
therapeutic success, this can be relevant in general dental care and
primary care as well as in specialised clinics. Adolescents with self-­ 2 | M E TH O D S
reported TMD pain have a three-­fold higher risk of having recurring
TMD pain as young adults, highlighting the importance of identifying Under the auspices of INfORM, the organising committee prepared
these individuals when pain first develops.14 a Satellite symposium “DC/TMD for children and adolescents” to
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EKBERG et al. 1169

be held in conjunction with the 2018 annual meeting of the IADR catastrophizing and sleep disorders) to measure psychosocial func-
in London, UK. As the first step, the Delphi method was used to tioning in adolescents.
achieve international consensus among experts in TMD who had The proposed adaptation of the DC/TMD, suggested by special-
experience of the DC/TMD. 25 Fifteen TMD experts, members of ists and experts, includes a comprehensive version for use in clinical
INfORM from around the world (AM, PA, CR, FK, SK, IMN, JD, and research settings and a short version for use by general practi-
ECE, RR, TL, RO, SS, MJR, MK, CCP), were invited to participate. tioners and other health care providers.
Thereafter, another nine experts (PS, FL, KW, CV, JPG, AA-­K , OK,
CH, PCC) in the field were added, and the first Delphi round was
created. 23 A facilitator (RR) developed a survey with 89 state- 3.2 | Recommendations for Axis I
ments, including Axis I and Axis II and the 23 Delphi members
were asked to respond to each statement on a five-­item Likert Clinical examination instruments can be seen in Tables 3 and 4.
scale ranging from “Strongly disagree” to “Strongly agree”. The 1. The 3Q/TMD questionnaire (Appendix S1) was introduced
members were also encouraged to leave free-­text comments. as a screener for TMD pain and dysfunction. The instrument is
After the third round, four experts in pain psychology (CB, TP, CK, easy to use and comprises three questions: two questions address
CP) in children and adolescents were invited to suggest instru- pain in the temporomandibular area and one question addresses
ments suitable for screening adolescents for depression, anxiety, dysfunction. Both questions on pain were initially assessed for
sleep disorders, catastrophizing and stress to improve the DC/ validity in adolescents [sensitivity 0.96 (95% CI, 0.85–­0 .99), spec-
TMD Axis II screening tools. ificity 0.83 (95% CI, 0.72–­0 .90)], and the reference condition was
The present paper includes both a comprehensive and a short-­ a TMD pain diagnosis according to RDC/TMD. 3 The complete
form version of the DC/TMD for adolescents (Appendix S1 and 3Q/TMD has been validated in the general population in adults
Appendix S2). and showed fair to moderate validity. For the question 3 on jaw
dysfunction sensitivity was 0.45 (0.38–­0 .52) and specificity 0.86
(0.80–­0 .90) and the reference condition was an intra-­articular
3 | R E S U LT S DC/TMD diagnosis. 27
2. The Symptom Questionnaire (SQ) was modified from the
3.1 | Overview adult version to be developmentally relevant for adolescents (SQ-­A)
(Appendix S1). Besides adapting of self-­reported patient information
Per the Delphi panel consensus23 the proposed adaptation of the on the history of pain characteristics, joint noises, jaw locking and
DC/TMD was developed for individuals in adolescence, defined by headache, new questions on trauma and numerical rating scales for
26
the WHO as the phase of life between 10 and 19 years of age. assessing TMD pain intensity and headache intensity were added.
Tables 1 and 2 present TMD diagnoses for adolescents in rela- 3. The language used in the Demographics questionnaire was
tion to the DC/TMD for adults. Two diagnoses, local myalgia and adapted to be developmentally relevant for adolescents. Questions
myofascial pain, were excluded for adolescents as no sensitivity on income and marital status were eliminated while questions on
and specificity have yet been established for adults. TMD-­pain di- family situation, school attendance and lifestyle were added in the
agnoses include arthralgia, myalgia, myofascial pain with referral Demographics questionnaire to be more useful for adolescents.
and headache attributed to TMD; intra-­articular TMD included six Also, two general health questionnaires concerning diseases and
diagnoses: disc displacement with reduction, disc displacement with medication, one for adolescent patients and one for their parents,
reduction with intermittent locking, disc displacement without re- were included (Table 1).
duction with limited opening, disc displacement without reduction 4. The clinical examination protocol for adolescents is iden-
without limited opening, degenerative joint disease and subluxation. tical to the protocol for adults (https://ubwp.buffa​lo.edu/rdc-­
Changes in Axis I of the DC/TMD include (i) adapting the language of tmdin​terna​t iona​l/). The mandatory commands are replaced by
the Demographics Questionnaire and the Symptom Questionnaire an explanation from the clinician of each examination procedure
to be developmentally appropriate for adolescents, (ii) adding two in an understandable way to the young individual. Explaining the
general health questionnaires, one for adolescent patients and one meanings of familiar pain and referred pain is critical. Adolescents
for their parents, (iii) replacing the TMD Pain Screener with the 3Q/ must understand that familiar pain is similar to what the individual
TMD questionnaire for screening and (iv) replacing the mandatory reports in the patient history in the last 30 days and reproduced
commands in the clinical examination with detailed instructions that during the clinical examination; referred pain is the pain perceived
could be used more easily to explain DC/TMD concepts to this pop- by the individual at a site away from the provocation and inter-
ulation (Appendix S1). preted by the examiner as beyond the boundary of the anatom-
Changes in Axis II include (i) adapting the language of the Graded ical structure being palpated. When analysing range of motion,
Chronic Pain Scale (GCPS) to be developmentally relevant for ado- a cut-­off of 40 mm for limited mouth opening capacity was set,
lescents, (ii) adding anxiety and depression assessment validated for as it was for adults. 28 Joint sounds are assessed during all man-
adolescents and (iii) adding assessment of three constructs (stress, dibular movements, as in the DC/TMD for adults. 29,30 During the
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1170 EKBERG et al.

TA B L E 1 The most common pain-­related temporomandibular disorders diagnoses in adults and adolescents according to the Diagnostic
Criteria for TMD (DC/TMD). Diagnoses are based on the patient history and clinical examination.

Diagnosis axis I Adults

DC/TMD History Clinical examination (≥20 years) Adolescents (10–­19 years)a

Myalgia Pain in the jaw, Confirmation of pain location(s) in the temporalis √ √

temple, in the and/or masseter muscle(s)
ear, or in front of Report of familiar pain in the temporalis or masseter
the ear with at least one of the following provocation
AND tests:
Pain modified with a. Palpation of the temporalis or masseter muscle(s)
jaw movement, OR
function, or b. Maximum unassisted or assisted opening
parafunction
Myofascial pain Same as for myalgia Same as for myalgia √ Comprehensive
with referral AND √
Sustained palpation with identification of referral Short form
patterns No
Arthralgia Same as for myalgia Confirmation of pain location in the area of the √ √
TMJ(s)
AND
Report of familiar pain 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, lateral
movements, or protrusive movements
Headache Headache of any type Confirmation of headache location in the area of the √ √
attributed to in the temple temporalis muscle(s) AND
TMD AND Report of familiar headache in the temple area with at
Headache modified least one of the following provocation tests
with jaw a. Palpation of the temporalis muscle (s)
movement, OR
function, or b. Maximum unassisted or assisted opening, lateral
parafunction movements, or protrusive movements
a
Unless otherwise indicated, the results for the adolescent versions of the comprehensive and the short form DC/TMD are the same.

palpation of the masticatory muscles and temporomandibular 3.3 | TMJ imaging

joints, the amount of pressure (0.5–­1 kg) and the time of palpation
(2 s when omitting identification of referred pain and 5 s when in- Referring an adolescent for TMJ imaging should only be done when
cluding identification of referred pain) is identical to what is used more information may influence the management or prognosis.
in the DC/TMD for adults (Appendix S2). The TMD experts on the Indications for TMJ imaging include: uncertain diagnosis, follow-­up
Delphi panel have recommended that future studies examine the on the lack of treatment effect and differential diagnosis of injuries
validity of familiar and referred pain during muscle and TMJ palpa- that may involve the TMJ. If any of these indications are present,
tion. Finally, supplemental muscle pain assessment with palpation the experts agreed upon using magnetic resonance imaging and/or
for the posterior mandibular region, the submandibular region, computed tomography (cone-­beam or axial) as a supplementary test
the lateral pterygoid area and the temporalis tendon is optional. to the DC/TMD for adolescents. 23
Mandatory palpation of these sites is generally unnecessary to
reach a DC/TMD muscle pain diagnosis (Table 4), whose sensitiv-
ity and specificity for adults were based on palpation of temporalis 3.4 | Recommendations for Axis II
and masseter muscles only due to very high prevalence of positive
findings in these two muscles alone. Instruments designed and validated to evaluate Axis II domains in
In the short form of the clinical examination, only opening capacity 10–­19-­year-­olds are needed. Instruments for pain-­related disability
and presence of familiar pain during movement should be recorded. and psychological status can be seen in Tables 3,5,6. The DC/TMD
Clicking and crepitation in the TMJ should be recorded only when Axis II instruments assessing pain location, pain intensity and gen-
opening and closing the mouth. Asking about referred pain is excluded eral physical functioning, physical symptoms and jaw parafunctional
from the short form and palpation time is reduced to 2 s (Table 2). behaviours were adapted and rephrased while the depression and
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EKBERG et al. 1171

TA B L E 2 The most common temporomandibular disorders (TMD) diagnoses in adults and adolescents according to the Diagnostic
Criteria for TMD (DC/TMD): Axis I, intra-­articular TMD.

Diagnosis Axis I DC/ Adults Adolescents

TMD History Clinical examination (≥20 years) (10–­19 years)a

Disc displacement
with reduction In the last 30 days, any TMJ noise(s) Clicking, popping and/or snapping √ Comprehensive
present with jaw movement or noise during both opening and √
function closing movements, detected Short form: only
OR with palpation during at least according
patient report of any noise during the one of three repetitions to opening/
examination OR closing
Noise as above during opening or movements
closing AND noise detected with
palpation during right or left
lateral, or protrusive movements
with reduction and As above AND As above √ Comprehensive
intermittent In the last 30 days jaw lock with limited √
locking mouth opening, even for a moment Short form: only
and then unlocks with a special according
manoeuvre to opening/
closing
movements
without reduction Jaw locked so that the mouth would Maximum assisted opening √ Comprehensive
with limited not open all the way AND movement including vertical √
opening Limitation in jaw opening severe incisal overlap <40 mm Short form: only
enough to limit jaw opening and according
interfere with ability to eat to opening/
closing
movements
without reduction As above Maximum assisted opening √ Comprehensive
without limited movement including vertical √
opening incisal overlap ≥40 mm Short form: only
according
to opening/
closing
movements
Degenerative joint In the last 30 days, any TMJ noise(s) Crepitus detected with palpation √ Comprehensive
disease present with jaw function during at least one of the √
OR following: opening, closing, Short form: only
Patient report any noise present during right or left lateral, or protrusive according
the exam movement(s) to opening/
closing
movements
Subluxation In the last 30 days, jaw locking or No exam findings are required √ √
catching in a wide-­open mouth
position, even for a moment, so
could not close from the wide-­open
position AND Inability to close the
mouth from a wide-­open position
without a self-­manoeuvre
a
Unless otherwise indicated, the results for the adolescent versions of the comprehensive and the short form DC/TMD are the same.

anxiety questionnaires in the DC/TMD for adults were replaced. can be found at https://ubwp.buffa​lo.edu/rdc-­t mdin​terna​t iona​l/.
Furthermore, for the comprehensive version, the Delphi panel For patients with widespread pain the recommendation is to use
recommended additional screening for stress, sleep disorders and the comprehensive DC/TMD. In the adolescent version, images of
catastrophizing. the face, the mouth and the body illustrate preselected areas that
1. The Pain Drawing is used to assess the self-­reported loca- facilitate the identification and reporting of locations of painful
tions of all pain complaints. It is included in the short and compre- sites.
hensive protocols. The Pain Drawing is useful for distinguishing 2. The GCPS includes questions for evaluating characteristic pain
between localised and widespread pain. 31 DC/TMD Pain Drawing intensity (CPI) and pain interference with daily activities. Reliability
 | 1172

TA B L E 3 Axis I (clinical examination) and Axis II (the pain-­related disability domain) instruments, recommended for use in adults by the Diagnostic Criteria for TMD (DC/TMD) and the
proposed version for adolescents aged 10–­19 years by the International Network for Orofacial Pain and Related Disorders Methodology (INfORM).

Adult version (ages ≥ 20 years) Proposed adolescent version (ages 10–­19 years)

DC/TMD domains Comprehensive Short Comprehensive Items (no.) Short Items (no.)

Axis I: Clinical examination

TMD screening Pain screener Pain screener 3Q/TMD 3 3Q/TMD 3
General Health‡
Adolescents –­ –­ newly developed 9 newly developed 9
Parents –­ –­ SF-­12 12 SF-­12 12
a a
Demographics Demo-­graphics Demo-­graphics Rephrased & modified 10 rephrased & modified 10
Symptom Questionnaire SQ SQ SQ -­A 18 SQ -­A 18
SQ rephrased & modifieda SQ rephrased & modifieda
Axis II: pain-­related disability
Pain intensity CPI CPI CPI 3 CPI 3
Physical functioning GCPS GCPS GCPS Rephraseda 8 GCPS Rephraseda 8
Pain locations Pain drawing Pain drawing Pain drawing incl preselected Pain drawing incl preselected
areasa areasa
Limitations JFLS-­20 JFLS-­8 JFLS-­20 20 JFLS-­8 8
Physical symptoms PHQ -­15 PHQ-­15 Rephraseda 14
Oral behaviours OBC-­21 OBC-­21 OBC-­21 21 Non-­functional activity 6
OBC

Abbreviations: 3Q/TMD, three questions for screening TMD; CPI, characteristic pain intensity; GCPS, graded chronic pain scale; JFLS, jaw functional limitation scale; OBC, Oral Behaviors Checklist; PHQ-­
15, patient health questionnaire-­15; SF-­12, the 12-­item Short Form survey; SQ, symptom questionnaire.
a
Same instrument as in the DC/TMD for adults.
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EKBERG et al. 1173

TA B L E 4 Axis I adaptations which

Axis I: clinical Adult version Proposed adolescent version (ages
the International Network for Orofacial
examination (ages ≥ 20 years) 10–­19 years)
Pain and Related Disorders Methodology
(INfORM) workshop recommends for use Comprehensive Comprehensive Short
in adolescents (Rongo et al.). 23,24
Commands Mandatory† Free explanations Free explanations
Jaw movements Full Full Opening movement
onlya
Limited opening capacity Full Full Full
Pain on jaw movements Full Full Opening movement
onlya
TMJ noises (at all Full Full Opening and closing
movements) movements onlya
Muscle palpation (Incl. Full Full 2 s onlya
familiar and referred
pain)
TMJ palpation (Incl. Full Full 2 s onlya
familiar and referred
pain)
a
As described in the DC/TMD for adults; full = the full examination as described in the adult
version of the DC/TMD for that section.

TA B L E 5 Axis II instruments for assessing psychological status, the Diagnostic Criteria for TMD (DC/TMD) recommend for adults and
version the International Network for Orofacial Pain and Related Disorders Methodology (INfORM) recommends for use in adolescents.

Adult version (ages ≥ 20 years) Proposed adolescent version (ages 10–­19 years)
Axis II instruments:
Psychological status Comprehensive Short Comprehensive Items (no.) Short Items (no.)

Depression PHQ -­9 PHQ -­4 RCADS-­SV 25 PHQ -­4 4

Anxiety GAD-­7 PHQ -­4 RCADS-­SV 25 PHQ -­4 4
Catastrophizinga
Adolescents PCS-­C 13
Parents PCS-­P 13
a
Sleep quality PSQI ISI ASWS 10
Stressa PSS-­10 PSS-­C 14

Abbreviations: ASWS, the 10-­item adolescent sleep wake scale; GAD-­7, the 7-­item generalised anxiety disorder screener; ISI, the 5-­item insomnia
severity index; PCS-­C , pain catastrophizing scale for children; PCS-­P, pain catastrophizing scale for parents; PHQ-­9, the 9-­item patient health
questionnaire; PSQI, the 9-­item the pittsburgh sleep quality index; PSS-­10, the 10-­item perceived stress scale; PSS-­C , the 14-­item perceived stress
scale for children; RCADS-­SV, revised child anxiety and depression scale-­short version.
a
Additional instruments recommended by INfORM.

and validity of the GCPS in adults has been confirmed, and the psy- DC/TMD for adolescents. For a short-­form adaptation of the DC/TMD
chometric properties of the 30-­day version of the GCPS has been for adolescents the frequency of non-­functional activities, including six
established in adults with TMD.32,33 The adolescent version of the items chosen after confirmatory factor analysis, was recommended.35,36
GCPS proposed here was developmentally adapted to adolescent The OBC non-­functional activities focus on tooth clenching-­related
activities, such that the pain interference questions were slightly re- wake-­time behaviours (e.g. clenching, grinding, holding), found to be as-
phrased. In cases of high pain, high interference and/or moderate to sociated with painful and dysfunctional TMDs.36 Future studies should
severe disability, the recommendation is to use the comprehensive validate the OBC non-­functional activities among 10–­19 year-­olds.
protocol for a more accurate assessment due to the high impact of 5. Like in the DC/TMD for adults, disease-­specific physical func-
pain in the patient's life. tioning in the proposed adolescent version is evaluated using the
3. The 15-­item Patient Health Questionnaire (PHQ-­15) was re- 20-­item Jaw Functional Limitation Scale (JFLS-­20) in the compre-
tained for evaluating non-­specific physical symptoms. It is also use- hensive protocol and the JFLS-­8 in the short protocol.37 The JFLS
ful for assessing comorbidities and overall symptom reporting. The is a questionnaire based on self-­reported jaw functional limitations,
question related to sexual intercourse was removed.34 assessing three domains: jaw opening, chewing and communica-
4. For assessing the frequency of oral behaviours, the Oral Behavior tion. The Delphi panel recommended its use in adolescents with no
Checklist (OBC) was recommended for the comprehensive form of modifications.
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1174 EKBERG et al.

TA B L E 6 Axis II instrument status description

Proposed adolescent version (ages 10–­19 years)

Items
Axis II instruments Comprehensive (no.) Status Short Items (no.) Status

Pain intensity CPI 3 To validate CPI 3 To validate

a a
Physical functioning GCPS Rephrased 8 To validate GCPS Rephrased 8 To validate
Pain locations Pain drawing incl To validate Pain drawing incl To validate
preselected areasa preselected areasa
Limitations JFLS-­20 20 To validate JFLS-­8 8 To validate
Physical symptoms PHQ-­15 Rephraseda 14 To validate
Oral behaviours OBC-­21 21 To validate Non-­functional activity 6 To validate
OBC
Depression RCADS-­SV 25 Validated PHQ -­4 4 To validate
Anxiety RCADS-­SV 25 Validated PHQ -­4 4 To validate
Catastrophizingb
Adolescents PCS-­C 13 Validated
Parents PCS-­P 13 Validated
Sleep qualityb ASWS 10 Validated
Stressb PSS-­C 14 Validated

Abbreviations: 3Q/TMD, three questions for screening TMD; ASWS, the 10-­item adolescent sleep wake scale; CPI, characteristic pain intensity;
GCPS, graded chronic pain scale; JFLS, jaw functional limitation scale; OBC, Oral Behaviours Checklist; PCS-­C , pain catastrophizing scale for
Children; PCS-­P, pain catastrophizing scale for parents; PHQ-­15 patient health questionnaire-­15; PSS-­C , the 14-­item perceived stress scale for
children; RCADS-­SV, revised child anxiety and depression scale-­short version; SQ, symptom questionnaire.
a
Same instrument as in the DC/TMD for adults.
b
New domains included after the Delphi study.

6. In the DC/TMD for adults, the 9-­item Patient Health an ordinal scale (0 = never, 1 = a little, 2 = sometimes, 3 = a lot) with
Questionnaire (PHQ-­9) and the 7-­item Generalised Anxiety Disorder a maximum score of 39. Higher scores refer to higher stress percep-
(GAD-­7) screeners are used to assess depression and anxiety, but tion, and normal value is ≤11 (mean 11.68, SD 3.5).41
they have not been validated in adolescents. The Delphi panel rec- 8. Two instruments have been proposed to investigate pain cat-
ommended the Revised Child Anxiety and Depression Scale-­Short astrophizing in adolescents and parents. The Pain Catastrophizing
Version (RCADS-­SV) that consist of 25 items: 10 for major depres- Scale for Children (PCS-­C) is a 13-­item questionnaire for subjects
sive disorders and 15 for anxiety; the RCADS-­SV is validated for aged 8–­17 years,42 and the Pain Catastrophizing Scale for Parents
38,39
populations aged 7–­18 years. Adolescents are asked to indicate (PCS-­P) is a 13-­item parent-­reported measure for describing the
how often each item in RCADS-­SV applies to them according to a catastrophic thinking of the parent about their child's pain.43 Both
4-­point rating scale (0 = never, 1 = sometimes, 2 = often, 3 = always). instruments include a 5-­point scale (0 = not at all, 1 = mild, 2 = mod-
Normative scores for depression is ≤8, and normative scores for anx- erately, 3 = severe, 4 = extremely) for children and (0 = not at all,
iety ≤12.38 The sum of all 25 items is computed and represents the 1 = to a slight degree, 2 = to a moderate degree, 3 = to a great de-
severity of general anxiety and depressive symptoms. Cronbach's gree, 4 = all the time) for parents. Score range is from 0 to 52, and
alpha for RCADS-­SV is a = 0.93 (sensitivity 0.84 and specificity higher levels indicate greater catastrophizing. Cronbach's alpha for
38
0.68). In the short version of the DC/TMD for adolescents, the in- PCS-­C is a = 0.87 in children with chronic or recurrent pain. This do-
strument recommended for assessing depression and anxiety is the main may indicate poor prognosis and possible pain persistence in
Patient Health Questionnaire 4 (PHQ-­4) 40 due to its brevity; how- adolescents. The PCS-­P has been used with parents of children with
ever, it has not been validated in adolescents. general chronic pain,44 but has not yet been used in parents of youth
The Delphi panel suggested the introduction of new domains for with TMD.
measuring stress, catastrophizing and sleep disorders; these are the 9. The Adolescent Sleep–­Wake Scale (ASWS), which explores
recommended areas to be investigated in the comprehensive TMD sleep quality in youth aged 12–­18 years, is a proposed addition to
protocol. the DC/TMD for adolescents.45 The scale is a 28-­item question-
7. The Perceived Stress Scale for Children (PSS-­C) is a screen- naire with a 6-­point response format (1 = always, 2 = frequently-­if
ing tool to capture an indication of perceived stress. The PSS-­C is a not always, 3 = quite often, 4 = sometimes, 5 = once in a while,
14-­item instrument validated in subjects aged 5–­18 years that can 6 = never). Overall, internal consistency has been found to be good
discriminate between those with and without stress. It consists of with a sensitivity of 0.80 and a specificity of 0.86 for the full scale.
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EKBERG et al. 1175

Moreover, ASWS-­S is a revised scale short form including 10 items, The DC/TMD includes headache attributed to TMD with specific
and this questionnaire is reliable (Cronbach's a = 0.80) and the Delphi criteria for the diagnosis; in parallel, the International Classification
panel recommends using it in the adolescent population for sleep of Headache Disorders, 3rd edition, defines headache attributed to
problems.46 TMD as a secondary headache.50 Headache in adolescents is signifi-
cantly associated with TMD pain, in both frequent headache (once a
week or more) and moderate or severe headache and in most adoles-
4 | DISCUSSION cents the onset of headache preceded TMD pain.51 Consequently,
the diagnosis of headache attributed to TMD should be retained in
4.1 | Overview the proposed version of the DC/TMD for adolescents.
The short and the comprehensive version of the DC/TMD proto-
There has been concern with tools for diagnosing TMD in adoles- col for adolescents were created for different situations. The short
cents. 2 General dental practitioners, TMD specialists, patients and version is intended for use in the initial assessment of clinical cases.
their families need a diagnostic system that is easy to understand Orofacial pain and its psychosocial impact are among the most fre-
and manage in the clinical setting. The goal of the new DC/TMD Axis quent reasons for patients to seek treatment in dentistry, 52 which is
I and Axis II for adolescents was to meet this challenge. why providing general practitioners with an easy and quick instru-
WHO has defined adolescence as the phase of life between ment for assessing both Axis I and Axis II is needed. The comprehen-
10 and 19 years of age, a wide range from prepubertal to young sive version is suggested for research settings and for the evaluation
adulthood and a period spanning a wide range of cognitive ability of more complex clinical cases when more details and information
in being able to understand and express one's own perspectives. are needed.
Adding more complexity for the clinician, the same adolescent can
demonstrate mature reasoning in one situation and less mature
in another. During adolescence, abstract thinking, self-­awareness 4.2 | Axis I
and self-­consciousness develop. The stage of development in
these domains influences how adolescents react and cope with The longitudinal study of Nilsson and List showed that to prevent
pain and jaw dysfunction. In clinical settings as well as in research pain from developing and becoming chronic, adolescents with TMD
settings, it can be difficult to interpret the signs and symptoms pain must be identified as early as possible.14 In a large group of ado-
reported by an adolescent. Their cognitive development is an in- lescents who had been screened for TMD pain, adolescents with
dividual and an ongoing process, making it difficult for clinicians TMD pain presented a three-­fold increased risk of self-­reported
to estimate the level of cognitive maturity in their adolescent pa- TMD pain as young adults compared to adolescents with no history
tients. While cognitive maturity affects how adolescents respond of TMD pain. A similar pattern has been found in a previous study,
to both clinical interview and to self-­report instruments the use of where history of chronic pain in childhood and adolescence was a
standardised assessment protocols in both clinical practice as well predictor for pain in young adults.53 Using screening questions for
as research afford the greatest possibility for reliable and valid TMD pain and jaw dysfunction makes it easier for general dental
assessment. practitioners, general practitioners and school healthcare services
PedIMMPACT is a recommended core outcome set for chronic to identify adolescents in need of treatment.
pain clinical trials based on the Initiative on Methods, Measurement The TMD screener 3Q/TMD includes two self-­reported pain
and Pain Assessment in Clinical Trials (IMMPACT) and designed for questions found to have very good reliability and validity in adoles-
children and adolescents.47 A consensus of experts identified core cents aged 12–­19 years.3 Lövgren et al. found the 3Q/TMD to be
domains and measures for clinical trials of potential treatments for valid in adults aged 20 years and older for recognising patients in
pain in the paediatric age group. A recent update of the core outcome need of a clinical TMD examination. 27 Because the 3Q/TMD has not
set recommends the inclusion of pain interference with daily living, been tested in ages 10–­19 years, the Delphi panel recommends re-
overall well-­being and adverse events, in addition to pain severity. liability and validity testing for this aspect of the DC/TMD for ado-
Emotional functioning, physical functioning and sleep are important lescents. The 3Q/TMD is designed for detecting patients in need of
but optional domains.48 Therefore, use of validated instruments that further assessment with the short or the comprehensive form of the
can assess these constructs is a prerequisite in the assessment pro- DC/TMD for adolescents.
cess. This is even more important in clinical research settings. The Symptom Questionnaire in the adult version of the DC/
In Axis I of the DC/TMD for adolescents, only two of the four TMD was modified for adolescents (SQ-­A) by adding a numerical
muscle pain diagnoses were included, that is, myalgia and myofascial rating scale to assess pain intensity and headache intensity, and a
pain with referral, because it is not yet known whether the mech- question on trauma history. The pain intensity scale is needed for
anisms and clinical implications of diagnostic subtypes of myalgia patients with acute pain who would not be completing the GCPS,
(local myalgia and myofascial pain) differ. Furthermore, no sensitiv- and it would help the clinician during follow-­up of the patient. As jaw
ity or specificity of these diagnostic subtypes has been reported in injury is strongly associated with incident TMD,54 and adolescents
49
adults. with prior head and/or neck injury are more likely to report TMD
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1176 EKBERG et al.

pain and to receive a TMD pain diagnosis,55 a question on trauma 4.3 | Axis II
was considered important.
Other modifications of the DC/TMD include the Demographic The Axis II instruments that the Delphi group recommended for re-
Questionnaire, entailing revision of the language and merging vision were the GCPS, the Pain Drawing and the OBC. The GCPS
General Health Questionnaires for adolescents and their parents grades pain intensity and pain disability according to predefined
with the demographic items. The parental health questionnaire normative values for patients 18 years and older who have head-
was the SF-­12 version 2 health survey.56 (Rand Health Care. 12-­ ache and TMD pain.32 It has been validated for 30-­day reference
Item Short Form Survey (SF-­12) Available from: https://www.rand. period. The language of the GCPS was developmentally adapted
org/healt​h -­c are/surve​y s_tools/​m os/12-­i tem-­s hort​-­f orm.html). for adolescents.33 In paediatric chronic pain an instrument simi-
(Accessed 29 February 2020). The adolescent health survey was lar to the GCPS has been used. This instrument for the grading of
compiled by authors in this study. Both these health questionnaires chronic pain, developed for adults by von Korff,32 has been found to
query the presence of other symptoms, of disease, and of medica- be a valid approach to classify severity grades of paediatric chronic
tion and of substance use. The introduction of these two surveys pain.66 A recent paper introduced the GCPS-­Revised (GCPS-­R), a 5-­
investigating general health aimed to detect the quality of patient's item instrument that is simple and valid for assessing chronic pain in
and parent's health, considering that general health is identified adults.67 The GCPS-­R might be of interest in the future as a screener,
57,58
as risk factors for TMD development in the adult population, in the short-­form version of the DC/TMD for adolescents.
and that parent's health influence on children's health; specifically, The Pain Drawing allows pictorial representation of the various
chronic pain in parents is associated with pain in their offspring, with pain locations. The proposed adaptation of the Pain Drawing for ad-
pain intensity, with activity limitations and with coping strategies re- olescents illustrates preselected areas focusing on common areas
lated to pain.59 of body pain, making it easier for the clinician to localise the sites.
The mandatory commands in the adult version were modi- The adolescent, however, is free to illustrate any pain outside of the
fied to include a list of detailed procedural instructions which selected areas that can be related to referred pain or other pain diag-
the consortium provides the clinician. With adolescent patients, noses not included in the DC/TMD for adolescents. Pain depictions
the authors suggest clinicians to use their own words to explain outside of the preselected areas can also be an expression of comor-
the examination, instead of using the mandatory commands. bidity. Comorbidities of TMD pain in adolescents have already been
The mandatory commands may be a barrier to implementing the identified for headache and other bodily pain.12,13,68
adult DC/TMD in general practice. In a general dentistry setting, There is a strong association between oral overuse behaviours
the diagnostic reliability of pain-­related TMD was unaffected in and the onset of painful TMD in adults.36,58,69,70 In adolescents asso-
Swedish adults when the mandatory commands were not used. 60 ciations of TMD pain with daytime parafunction (for example grind-
The Delphi panel considered it important to clearly explain two ing, clenching, gum chewing) have been found.71,72 To evaluate oral
concepts during the clinical examination: the meanings of familiar overuse behaviours in adolescents, the OBC-­21 adult version was
pain and of referred pain. chosen for the comprehensive version, and the six items version is
The consensus of the authors of Part 1 of the Delphi study is included in the short version. The OBC-­6 for adolescents focuses on
that TMJ imaging in adolescents should be performed only when non-­functional activities such as tooth clenching related to wake-­
needed. 23 CBCT and MRI with or without contrast can be very use- time oral behaviours. However, it can be questioned if the included
ful in the diagnosis and management of some joint-­related TMDs. A items in both versions are easy to understand or not in adolescents
recent systematic review with meta-­analysis reported a high spec- and its validity will be tested.
ificity (98%) of both RDC/TMD and DC/TMD for the diagnosis of On a psychological level, the Delphi panel supported the in-
disc displacement without reduction, however the sensitivity for troduction of new instruments to Axis II for screening psychoso-
the disc displacement with reduction and disc displacement with- cial health in adolescents. 24 Adolescents are faced with numerous
61
out reduction were respectively 66% and 61% in adults. Using the stressors including seeking social acceptance, performing at school
criterion standard of MRI improves diagnosis of these disc displace- and in their leisure time and maintaining family relationships. A
ments, but costs and benefits of such tests needs to be assessed for WHO-­initiated project in first-­year college students in eight coun-
each patient, particularly as this condition is common in asymptom- tries found that at least one-­third reported a history of at least one
atic patients (15%–­32%).62–­6 4 or more mental health disorders.73 Life stress contributed substan-
In 2020, the distribution of doses absorbed by adult and child tially to the development of a wide range of health issues in adoles-
phantoms during panoramic radiographs and cone-­beam computed cents,74 including several pain conditions.75,76
tomography of the TMJ has been compared. The bone surface and Chronic pain in general is often associated with depression
the salivary glands received the highest absorbed doses compared and anxiety, sleeping problems and reduced cognitive function in
to other tissues, and the radiation burden on the adult phantom adults.77,78 Similarly, use of screening instruments in Axis II can help
65
was generally higher than on the child phantom. As growth and clinicians to determine the impact of chronic pain on the lives of ad-
development varies considerably in adolescents, clinicians should olescents and how they have managed their pain. Screeners can also
consider carefully before referring an adolescent for TMJ imaging. simplify clinical decision-­making concerning TMD pain prognosis
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EKBERG et al. 1177

and management. Furthermore, stress such as from challenges in in adolescents. We thus emphasise the need for reliability and valid-
school and in the family is commonly associated with TMD onset ity testing in coming studies. A final DC/TMD for adolescents will
in adolescents.7 LeResche (2007) identified negative somatic and be presented after consistency and validity of all instruments is
psychological symptoms, other pain complaints and life dissatisfac- completed. The Axis I and Axis II instruments are presently avail-
tion as risk factors for the onset of clinically significant TMD pain in able in English. For those instruments that are part of the DC/TMD,
6
adolescents. These findings suggest that the development of TMD currently existing translations of the DC/TMD will be amenable to
pain in adolescence may reflect an underlying vulnerability to mus- relatively easy modification for a DC/TMD-­ Adolescent (DC/TMD-­
culoskeletal pain that is not unique to the orofacial region. Thus, an A). For those instruments that are not part of the adult DC/TMD,
assessment of TMD pain should include psychological factors to de- translation will be required for use in other languages according to
pict a holistic view of the patient. INfORM recommendations.84
The Delphi group recommended the PHQ-­4 for the short-­form
DC/TMD for adolescents and the RCADS-­SV for the comprehen-
sive form. The PHQ-­4 is a screener easy to use in general dental 5 | CO N C LU S I O N
practice to measure psychological distress; however, it has not been
validated in adolescents. The proposed DC/TMD protocol for adolescents is intended for use
Other questionnaires to screen for anxiety, depression and in all clinical and research settings. It includes instruments from sim-
three other constructs (stress, catastrophizing and sleep disor- ple screening of TMD, the clinical criteria for the most common TMD
ders) to assess psychosocial functioning were included; these diagnoses as well as Axis II instrument screeners specific for adoles-
have all been validated in adolescents. The RCADS-­S V is a 25-­ cents, for assessing psychological status and pain-­related disability.
items questionnaire, tested in the ages 7–­18 year and provides an Validity and reliability testing of instruments are needed to finalise
efficient assessment of the general problem areas of anxiety and the first formal version of DC/TMD for adolescents.
38
depression. The RCADS-­S V might help the clinician understand-
ing the patient's pain experience and determining the most appro- AU T H O R C O N T R I B U T I O N S
priate interventions. Roberto Rongo, EwaCarin Ekberg, Ing-­Marie Nilsson, Ambrosina
To screen for catastrophizing, the Delphi panel recommended Michelotti conception and design of study; Roberto Rongo, EwaCarin
the PCS-­C for adolescents and the PCS-­P for parents. Pain cata- Ekberg, Ing-­Marie Nilsson, Ambrosina Michelotti acquisition of data;
strophizing is considered an important psychological correlate of Roberto Rongo, EwaCarin Ekberg, Ing-­Marie Nilsson, Ambrosina
pain chronicity and disability,79,80 and catastrophic thinking about Michelotti data analysis and/or interpretation; Amal Al-­Khotani, Per
pain also occurs in adolescents and is a determinant of adjustment Alstergren, Paulo Cesar Rodrigues Conti, Justin Durham, EwaCarin
81
to pain. Exploratory factor analysis with a random subsample of Ekberg, Jean-­Paul Goulet, Christian Hirsch, Stanimira Kalaykova,
adolescents found that either the revised 11-­item or the original 13-­ Flavia P. Kapos, Christopher D. King, Osamu Komiyama, Michail
item PCS can be used with this population for calculating subscale Koutris, Thomas List, Frank Lobbezoo, Ambrosina Michelotti, Ing-­
scores.42,82 To screen for stress, the Delphi panel recommended the Marie Nilsson, Richard Ohrbach, Tonya M. Palermo, Christopher
PSS-­C , an instrument that is found to be valid in evaluating stress C. Peck, Chris Penlington, Claudia Restrepo, Maria Joao Rodrigues,
in 5-­18-­year-­olds.41 Psychosocial distress is an etiological factor for Roberto Rongo, Sonia Sharma, Peter Svensson, Corine M. Visscher,
developing painful TMD in adults,77 and also an important factor to Kerstin Wahlund drafting of manuscript and/or critical revision Amal
consider in adolescents.75 Al-­Khotani, Per Alstergren, Paulo Cesar Rodrigues Conti, Justin
To screen for sleep disorders, the Delphi group suggested the Durham, EwaCarin Ekberg, Jean-­Paul Goulet, Christian Hirsch,
ASWS-­S, which has shown good, overall internal consistency, Stanimira Kalaykova, Flavia P. Kapos, Christopher D. King, Osamu
Cronbach's Alpha to be around 0.8, among ages 12–­18.45 Adolescents Komiyama, Michail Koutris, Thomas List, Frank Lobbezoo, Ambrosina
with comorbid musculoskeletal pain and sleep problems experience Michelotti, Ing-­Marie Nilsson, Richard Ohrbach, Tonya M. Palermo,
psychological distress and greater pain intensity compared to ado- Christopher C. Peck, Chris Penlington, Claudia Restrepo, Maria Joao
lescents with no comorbidities.83 Rodrigues, Roberto Rongo, Sonia Sharma, Peter Svensson, Corine M.
The present article presents the core assessment instruments at Visscher, Kerstin Wahlund approval of final version of manuscript.
the time of publication. Interested clinicians and researchers should
consult the INfORM website for up-­to-­date versions of instruments. A F F I L I AT I O N S
1
Department of Orofacial Pain and Jaw Function, Faculty of Odontology,
Malmö University, Malmö, Sweden
2
Center for Oral Rehabilitation, Norrköping, Sweden
4.4 | Future directions 3
School of Orthodontics, Department of Neurosciences, Reproductive
Sciences and Oral Sciences, University of Naples Federico II, Naples, Italy
This first version of the DC/TMD for adolescents is a result of the 4
Dental Department, East Jeddah Hospital, Ministry of Health, Jeddah,
Delphi process, and some of the instruments have not been validated Saudi Arabia
 |

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1178 EKBERG et al.

5
Scandinavian Center for Orofacial Neurosciences, Malmö, Sweden ORCID
6
Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden Ing-­Marie Nilsson https://orcid.org/0000-0002-0550-8925
7
Department of Prosthodontics and Periodontology, Bauru School of Amal Al-­Khotani https://orcid.org/0000-0001-7168-9835
Dentistry–­University of São Paulo, Bauru, Sao Paulo, Brazil
8
Paulo Cesar Rodrigues Conti https://orcid.
Bauru Orofacial Pain Group, University of São Paulo, Bauru, Sao Paulo,
Brazil
org/0000-0003-0413-4658
9
Newcastle School of Dental Sciences, Newcastle University, Newcastle
Christian Hirsch https://orcid.org/0000-0002-3773-6623
upon Tyne, UK Flavia P. Kapos https://orcid.org/0000-0002-6224-273X
10
Faculty of Dental Medicine, Laval University, Quebec, Quebec, Canada Frank Lobbezoo https://orcid.org/0000-0001-9877-7640
11
Clinic of Pediatric Dentistry, University of Leipzig, Leipzig, Germany Richard Ohrbach https://orcid.org/0000-0002-9266-9734
12
Department of Oral Function and Prosthetic Dentistry, College of Dental Chris Penlington https://orcid.org/0000-0002-2695-7041
Sciences, Radboud University Medical Center, Nijmegen, The Netherlands Claudia Restrepo https://orcid.org/0000-0002-0695-7562
13
Department of Epidemiology, University of Washington, Seattle, Sonia Sharma https://orcid.org/0000-0002-1887-7420
Washington, USA
Corine M. Visscher https://orcid.org/0000-0002-4448-6781
14
Center for Child Health, Behavior and Development, Seattle Children's
Kerstin Wahlund https://orcid.org/0000-0003-2236-8546
Research Institute, Seattle, Washington, USA
15
Division of Behavioral Medicine and Clinical Psychology, Cincinnati
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