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he measurable and reproducible set of Clinical Diagnostic Criteria for Temporomandibular Disorders, or CDC/TMD, for the most common forms of TMD was published in 1992 to provide a standardized definition of diagnostic subgoups of patients with orofacial pain and TMDs.1 Each criterion refers to a particular examination and interview item, and each item is accompanied by A clinical specifications on how to perform the diag2 temporo- nostic procedure. CDC/TMD was developed in an attempt mandibular to form a common set of working criteria joint–related for classifying subjects in TMD epidemidiagnosis of ology and treatment studies. It classifies internal the most common forms of TMD into the derangement main diagnostic subgroups of masticatory type III may muscle disorder; temporomandibular joint, or TMJ, internal derangement, or ID; and need to be TMJ degenerative joint disease. To verify supplemented that these disorders and diseases represent by evidence distinct entities, data supporting decisive from a differences in the areas of pathogenesis, 3 magnetic treatment and prognosis are essential. resonance Validating the masticatory muscle disorder subgroup may be difficult because of the image. lack of available definitive diagnostic procedures or of “biological gold standards” that may define some pathological changes.4-6 TMJ imaging techniques, on the other hand, can be used to validate the diagnostic criteria for TMJ ID

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RÜDIGER EMSHOFF, M.D., D.M.D.; IRIS BRANDLMAIER, M.D.; STEFAN BERTRAM, M.D., D.M.D.; ANSGAR RUDISCH, M.D.

Background. Research is needed to assess the validity of the Clinical Diagnostic Criteria for Temporomandibular Disorders, A D A J or CDC/TMD. The authors conducted a ✷ ✷ prospective, double-blind study to deter-  mine whether applying the specific CDC/TMD diagnosis of TMJ internal N C U derangement, or ID, type III would A U I NdemonD 1 RT G E strate good agreement with diagnoses ICLE obtained by MRI. Methods. The study comprised 138 TMJs in 69 subjects who had a clinical diagnosis of unilateral TMJ ID type III (disk displacement without reduction). The authors obtained bilateral sagittal and coronal MRIs to establish the corresponding diagnosis of disk-condyle relationship. Results. For the CDC/TMD interpretations, the positive predictive value of ID type III for disk displacement without reduction was 86 percent, and for the presence of an ID it was 91 percent. The overall diagnostic agreement for ID type III was 78.3 percent with a corresponding κ value of 0.57. Most of the disagreement was due to false-positive interpretations of an absence of ID. Conclusions. The results suggest that using CDC/TMD for ID type III is predictive for the presence of an ID but is not sufficiently reliable for determining disk displacement without reduction. Parameters other than the functional disk-condyle relationship may need to be addressed to account for the biological plausibility of this entity. Clinical Implications. A clinical TMJrelated diagnosis of ID type III may need to be supplemented by evidence from an MRI to determine the functional disk-condyle relationship. Investigation of longitudinal evidence, including risk factors, history and response to treatment, appears to be warranted. CON

Comparing methods for diagnosing temporomandibular joint disk displacement without reduction

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and TMJ degenerative joint disease. Magnetic resonance imaging, or MRI, is the most accurate imaging modality for identifying TMJ disk positions and may be regarded as the “gold standard” for disk position identification purposes.7 A

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study of observer variation when the classification system proposed by Tasaki and colleagues8 is used has shown a low level of intraobserver and interobserver variability.9 We conducted this prospective, double-blind study to determine whether applying the specific CDC/TMD diagnosis of TMJ ID type III would demonstrate good agreement with diagnoses obtained by MRI. MATERIALS AND METHODS

Subjects. The study group consisted of 69 consecutively seen patients referred from medical practitioners and dentists in the community to the Orofacial Pain and Temporomandibular Disorder Clinic in the Department of Oral and Maxillofacial Surgery at the University of Innsbruck, Austria. This clinic is the primary referral center for TMD at the university, and it offers both conservative and surgical treatments. There were 59 female patients and 10 male patients, who had a mean age of 35.9 years (range, 12-79 years). We informed the subjects about the study procedure and obtained their written informed consent. Criteria for inclusion in the study were unilateral signs and symptoms characteristic of a TMJrelated diagnosis of ID type III (disk displacement without reduction), absence of a contralateral diagnosis of ID type I (disk displacement with reduction) or ID type II (disk displacement with reduction and episodic catching), no concomitant TMD diagnosis of degenerative joint disease, absence of signs and symptoms that characterized a diagnosis of myalgia, no history of trauma and absence of collagen vascular disease. To determine the reliability of the clinical diagnosis of TMJ ID type III compared with MRI diagnosis, we clinically evaluated the subjects and then had them undergo MRI investigation. One clinician (R.E.) performed the clinical evaluation of each subject. The clinical assessment consisted of a standardized evaluation of mandibular range of motion, joint pain and auscultation of joint sounds. Mandibular range of motion was evaluated for maximum opening and lateral movements; maximum opening was measured from central maxillary incisor to the opposing mandibular incisor, using a millimeter ruler. The clinician measured lateral movements relative to the maxillary midline with the teeth slightly separated. TMJ pain was identified during palpation,

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mandibular range of motion or assisted mandibular opening. The TMJs were auscultated with a stethoscope, with the subject performing three openings and three lateral and protrusive movements. The joint sounds were described as single and reciprocal clicks.2 We made clinical TMD diagnoses based on the CDC/TMD (Table 1).1 The TMJ ID type III subgroup was defined by the CDC/TMD1 as subjects having a history of sudden reduction in mandibular opening, an unassisted mandibular opening less than 35 mm and an assisted mandibular opening increased by 3 mm or less than an unassisted opening. In subjects with a history of clicking, click disappearance and sudden decreased opening needed to coincide. If there was an absence of clinical inclusion criteria defining one of the ID subgroups, we accepted clinical evidence of absence of disk displacement. The single clinician (R.E.) performed the clinical evaluations and followed a structured protocol.2,10,11 The intraobserver reliability was satisfactory (κ > 0.75) to excellent (κ = 1.00) for all of the CDC/TMD items; the majority had a κ value of 1.00. MRI. Using MRI, a single radiologist (A.G.) made the diagnoses of the disk-condyle relationship. We carried out MRI with a 1.5 tesla MRI scanner and a dedicated circular-polarized transmit-and-receive TMJ coil. The data were collected on a 252 × 256 dots-per-inch matrix with a field of view of 145 mm, giving a pixel size of 0.60 × 0.57 mm. With the subject in a supine position, we obtained 15 coronal slices and eight parasagittal slices of each TMJ using a turbo-spinecho–proton-density sequence (repetition time, 2,800 milliseconds; echo time, 15 ms) with thin 3-mm slices. MRIs were corrected to the horizontal angulation of the long axis of the condyle. We made sequential bilateral images with the subjects’ mouths closed and at the respective maximum mouth-opening positions. The radiologist (A.R.) assessed the MRIs using established criteria for normal disk position vs. disk displacement. We defined normal disk position as the posterior band of the disk’s being located at the superior, or 12 o’clock, position relative to the condyle, whereas we defined disk displacement as the posterior band of the disk’s being in an anterior, anteromedial, anterolateral, medial or lateral position relative to the superior

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TABLE 1

CLINICAL DECISION CRITERIA FOR TMD* DIAGNOSTIC CATEGORIES.† TMD DIAGNOSIS

REQUIRED DIAGNOSTIC (OPERATIONAL CRITERIA)

Myalgia Type I Mild masticatory muscle symptoms

dReport of orofacial pain dMuscle palpation pain in two or more muscle sites (masseter, temporalis, tendon of the temporalis, suprahyoids, stylohyoid region, lateral pterygoid) with muscle palpation pain of 2 or more on a 0 to 3 scale in no more than a single muscle site

Myalgia Type II Moderate/severe masticatory muscle symptoms

dReport of orofacial pain dMuscle palpation pain in two or more muscle sites (listed above) with two or more muscle sites rated 2 or greater on a 0 to 3 scale

Myofacial Pain Dysfunction Muscle pain with jaw dysfunction

dMyalgia type I or II dUnassisted mandibular opening of less than 40 millimeters and mandibular opening with assistance of 4 mm or more greater than unassisted opening

Internal Derangement Type I Disk displacement with reduction

dClick in the TMJ‡ during mandibular range of motion dClick in the TMJ during lateral or protrusive excursion dNormal closing with or without clicking

Internal Derangement Type II Disk displacement with reduction and episodic catching

dSame as internal derangement type I with periods of catching briefly during opening

Internal Derangement Type III Disk displacement without reduction

dUnassisted mandibular opening less than 35 mm dMandibular opening with assistance increased by 3 mm or less than unassisted opening dHistory of sudden reduction in opening dIf history of click, click disappearance and sudden decreased open coincide

Capsulitis/Synovitis

dPain in the joint during palpation dPain in the joint during function dPain in the joint during assisted opening

Sprain/Strain—Trauma Related

dSame as capsulitis plus dHistory of recent trauma preceding onset of pain dPain on right or left excursions, or pain on protruded or retruded movement

Perforation of the Posterior Ligament/Disk

dNo distinctive clinical criteria

Degenerative Joint Disease— Arthritis/Arthrosis— With Arthralgia

dSame as capsulitis plus absence of positive laboratory tests for collagen vascular disease dHard grating or crepitus must be present for a clinical diagnosis of degenerative joint disease

Degenerative Joint Disease— Arthritis/Arthrosis— Without Arthralgia—of Aging, Traumatic, Idiopathic

dSame as degenerative joint disease with arthralgia except absence of pain in joint during palpation, function or excursion

Collagen Vascular Diseases Systemic Disease With Local Involvement

dSame as capsulitis plus dPositive laboratory tests for immune system disease or presence of clinical criteria required for a diagnosis of collagen disease

* TMD: Temporomandibular disorder. † Modified from Truelove and colleagues.1 ‡ TMJ: Temporomandibular joint.

part of the condyle. We categorized diagnosis of the disk-condyle relationship as normal (absence of ID) (Figure 1), disk displacement with reduction (Figure 2, page 446) and disk displacement without reduction (Figure 3, page 447). We based our categorizations on the finding of a closed–mouth-related diagnosis of absence or 444

presence of disk displacement associated with or without an open–mouth-related interposition of the disk between the condyle and the articular eminence.8 Data analysis. We evaluated the statistical significance of the diagnostic percentage agreement between the clinical findings and MRI diag-

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Figure 1. Magnetic resonance images, or MRIs, of a patient with a right-side–related clinical diagnosis of temporomandibular joint, or TMJ, internal derangement, or ID, type III, with absence of ID. A. Sagittal closed-mouth–related MRI shows posterior band of the disk (arrows) superior to condyle. B. Sagittal open-mouth–related MRI shows disk superior to condyle (arrows).

noses using the κ statistical test and determined the predictive value of the CDC/TMD for ID type III. The resulting κ values determined the level of agreement corrected by chance. We used a specialized software package (SPSS, Version 7.5.2G, SPSS Inc., Chicago) to conduct all of the statistical analyses. RESULTS

The MRI diagnoses made by the radiologist are shown in Table 2 (page 448). In the 69 TMJs with a clinical diagnosis of absence of ID, we made an MRI diagnosis of absence of ID in 25 (36.2 percent), while we found that 24 (34.8 percent) had a diagnosis of disk displacement with reduction and 20 (29.0 percent) had a diagnosis of disk displacement without reduction. In the 69 TMJs with a clinical diagnosis of ID type III, we made an MRI diagnosis of TMJ ID in 63 (91.3 percent); four (5.8 percent) had a diagnosis of disk displacement with reduction, and 59 (85.5 percent) had a diagnosis of disk displacement without reduction. We found that in 84 TMJs, MRI validated the disk-condyle relationship. Among TMJs with an MRI diagnosis of an absence of ID and disk displacement without reduction, there were 25 truepositive and six false-negative findings for the absence of ID group, and 59 true-positive and 20 false-negative findings for the ID type III group (Table 3, page 448). The sensitivity for detection of absence of ID was 81 percent and the speci-

ficity was 59 percent (Table 4, page 449). For detection of disk displacement without reduction, the sensitivity was 75 percent and the specificity was 83 percent. Among TMJs with a CDC/TMD diagnosis of absence of ID, MRI showed that 25 had an absence of ID (positive predictive value, or PPV, 36 percent) and 44 had a presence of ID (negative predictive value, or NPV, 91 percent) (Table 4). Of the TMJs with a CDC/TMD diagnosis of ID type III, 59 had disk displacement without reduction (PPV, 86 percent) and 10 had an absence of ID type III (NPV, 71 percent). The presence of an ID was diagnosed correctly by CDC/TMD in 63 of the 69 TMJs with an ID type III (PPV of 91 percent). Comparing the agreement of the clinician relative to the MRI diagnoses, the κ values for ID and ID type III rated 0.28 and 0.57, respectively, indicating poor agreement with the MRI diagnosis of ID and fair agreement with that of disk displacement without reduction (Table 5, page 449). DISCUSSION

In this study, we used a set of specified operational criteria to classify patients who have TMD. This approach to clinical measurement produced a high correlation between the prospective CDC/TMD diagnosis of ID type III and the findings at MRI, with a PPV of 86 percent for disk displacement without reduction and 91 percent for ID.

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Figure 2. Magnetic resonance images, or MRIs, in a patient with a right-side–related clinical diagnosis of temporomandibular joint, or TMJ, internal derangement type III, with presence of disk displacement with reduction. A. Sagittal closed-mouth–related MRI shows posterior band of the disk (arrows) anterior to condyle. B. Coronal closed-mouth–related MRI shows disk anterolateral to condyle (arrows). C. Sagittal open-mouth–related MRI shows posterior band of the disk (arrows) superior to condyle. D. Coronal open-mouth–related MRI shows disk superior to condyle (arrows).

To our knowledge, no previous study has investigated systematically the diagnostic value of CDC/TMD for assessing MRI diagnoses of ID. Various TMD findings have been reported, but their predictive values in specified subject-related CDC/TMD subgroups are not known. Barclay and colleagues12 described PPV, NPV and accuracy of specific clinical diagnoses in the detection of ID in a study. That work used the Research Diagnostic Criteria for TMD, or RDC/TMD, and was performed with a study group of 40 consecutive patients clinically diagnosed with disk displace446

ment with reduction in at least one TMJ. It had a PPV of 56 percent for disk displacement with reduction, a PPV of 92 percent for ID and a preponderance of false-negative errors, especially for asymptomatic TMJs. Comparison of the reported values with those of our current study, however, may not be possible, as Barclay and colleagues’ study was performed to assess the validity of the RDC/TMD subgroup of disk displacement with reduction. To classify the use of CDC/TMD for the assessment of MRI diagnoses of ID with appropriately tested validity, further studies comparing MRI data with those of specific diagnostic subgroups offering a high degree of intra- and interobserver reliability

may be warranted.13 Several authors have investigated the accuracy of clinical diagnosis for TMJ ID using arthrography and MRI as a gold standard. The reported percentage agreement ranged from 59 percent to 90 percent, depending on the diagnostic criteria used in the respective studies.14-22 Some authors investigated single items of mandibular range of motion, TMJ sounds, dental occlusion, TMJ pain and masticatory muscle pain in their predictive value of TMJ ID.14-19 Other authors used strict inclusion criteria for one diagnosis, but failed to

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revealed an unacceptable agreement between the clinician in his diagnoses of ID type III and the radiologist in his corresponding MRI diagnoses of disk displacement without reduction. This finding may reflect the difficulty in separating the absence of ID group from the ID A B type I group, as the absence of ID group was not defined as a wellness gold standard without signs and symptoms or history of TMD. The only difference between these diagnostic groups in specified diagnostic criteria was the absence of clicking during vertical mandibular range of motion or lateral C D or protrusive Figure 3. Magnetic resonance images, or MRIs, in a patient with a left–side-related clinical excursions (Table diagnosis of temporomandibular joint, or TMJ, internal derangement type III, with presence of anterior disk displacement without reduction. A. Sagittal closed-mouth–related MRI shows disk 1). Further, it con(arrows) anterior to condyle. B. Coronal closed-mouth–related MRI showing anterior disk disfirms the results of placement (arrows). C. Sagittal open-mouth–related MRI shows disk (arrows) anterior to previous studies condyle. D. Coronal open-mouth–related MRI shows disk anterior to condyle (arrows). that suggest disk displacement to be prevalent in asymptomatic describe essential characteristics that distinguish TMJs in up to 21 percent to 33 percent.8.23 With a one diagnosis from another.20-22 This ambiguity between essential and nonessential features of percentage agreement of 78.3 percent for ID type the various TMD subgroups may have resulted in III, the plausibility of disk displacement may be low reliabilities concerning the classification of questioned. As the decision criteria may be highly patient groups in these studies. With regard to specific for a “locked joint,” other parameters may the diagnostic system applied in our current have to be addressed to account for the biological study, the overall intra- and interobserver reliaplausibility of these enities.24,25 bility has not been tested yet; however, the use of Several studies have focused on the importance strict inclusion and exclusion criteria may have of disk displacement as the underlying mechadefined homogeneous clinical subgroups of nism in the etiology of TMJ-related pain and dyspatients who have TMDs. function.8,23,26,27 With the observation that arthroBased on our study, clinical classification scopic lysis and lavage, as well as arthrocentesis JADA, Vol. 133, April 2002 Copyright ©2002 American Dental Association. All rights reserved.

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in synovial fluid viscosity have been proMRI* DIAGNOSIS OF TYPE OF INTERNAL DERANGEMENT posed as etiologic proIN SUBJECTS WITH A UNILATERAL CDC/TMD† DIAGNOSIS cesses in the OF DISK DISPLACEMENT WITHOUT REDUCTION.‡ development of restricted gliding MRI DIAGNOSIS CDC/TMD DIAGNOSIS movements of the mandibular condyle Total (%) Absence of Internal Internal Derangement (%) Derangement Type over the articular emiIII (%) nence.34 Further 31 (22.5) Absence of Internal 25 (36.2) 6 (8.7) research, however, Derangement may be warranted to 28 (20.3) Disk Displacement 24 (34.8) 4 (5.8) assess underlying variWith Reduction ables as possible initi79 (57.3) Disk Displacement 20 (29.0) 59 (85.5) ating, predisposing or Without Reduction perpetuating factors in 138 (100) TOTAL 69 (100) 69 (100) the etiology of certain TMJ-related pain and * MRI: Magnetic resonance imaging. † CDC/TMD: Clinical diagnostic criteria for temporomandibular disorders. dysfunction conditions. ‡ N = 138 temporomandibular joints. In our current study, we used the gold TABLE 3 standard MRI criterion CDC/TMD* DIAGNOSES OF INTERNAL DERANGEMENT (the 12 o’clock position) to define normal disk position,35,36 and we FINDINGS INTERPRETATION OF CDC/TMD DIAGNOSIS determined the PPV and NPV of CDC/TMD Internal Total (%) Absence of Derangement Internal parameters for preType III (%) Derangement (%) dicting the condition of True-Positive 25 59 84 the TMJ established by this criterion. Disk disTrue-Negative 63 49 112 placement according to False-Negative 6 20 26 this criterion, however, False-Positive 44 10 54 has been observed in * CDC/TMD: Clinical diagnostic criteria for temporomandibular disorders. normal, asymptomatic † N = 138 temporomandibular joints. volunteers, raising the question of what and hydraulic distension of the upper joint space, should be considered an abnormal disk posiare associated significantly with a reduction in tion.8,23,37-39 In terms of disease classification, a TMJ-related pain and an increase in mandibular more accurate diagnostic operational criterion to range of motion, the diagnostic and therapeutic define TMJ disk displacement may be needed. significance of TMJ disk displacement has been One that is related closely to the clinical signs questioned by several authors.28-31 Arthroscopic and symptoms of the disorder may be needed to studies have confirmed that inflammatory procavoid over- and undertreatment and to obtain a esses of the synovium, capsule or retrodiskal tismore cost-effective outcome. sues are the underlying mechanisms for the The findings of our study raise the question of occurrence of TMJ-related pain.32 Since any whether the use of clinical diagnostic criteria in impediment in the upper or lower joint space may clinical settings may need to be supplemented by result in a restriction of range of mandibular imaging techniques to distinguish among submotion, alterations in the constituents of the syntypes of TMD. Arthrographic and MRI evaluation ovial fluid affecting the lubrication of the TMJ,33 of the soft-tissue components of the TMJ may not as well as reversible adhesions of the disk to the always be available. Arthrography is an invasive glenoid fossa caused by vacuum effects or changes technique, and MRI use may be limited by cost; 448

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thus, most of the eval- TABLE 4 uative approaches for PROSPECTIVE CDC/TMD* DIAGNOSIS OF INTERNAL patients who have DERANGEMENT TYPE.† TMD are symptombased. Therefore, sevFINDINGS INTERPRETATION OF CDC/TMD DIAGNOSIS eral studies have been Internal TOTAL (%) Absence of conducted to deterDerangement Internal Type III (%) Derangement (%) mine the accuracy of clinical and adjunctive Sensitivity 81 75 76 diagnostic tests; the Specificity 59 83 68 accuracy rates Positive Predictive Value 36 86 61 obtained for TMJ ID have ranged from 43 Negative Predictive Value 91 71 81 percent to 90 percent.18,20,22,24,40-42 * CDC/TMD: Clinical diagnostic criteria for temporomandibular disorders. Questions also have † N = 138 temporomandibular joints. arisen as to which diagnostic approach should be selected and TABLE 5 how the test results DIAGNOSTIC AGREEMENT AND RELIABILITY should be interpreted. BETWEEN CLINICIAN AND MRI.*† The choice of criterion may depend on the relCDC/TMD ‡ DIAGNOSIS TMJ § GROUP ative values the deci¶ Value Percentage in Diagnostic sion maker places on Agreement (n) making false63.8 (88) 0.28 Internal Derangement positive and false-negative diag78.3 (108) 0.57 Internal Derangement III noses, as well as the * MRI: Magnetic resonance imaging. changes in treatment † N = 138 temporomandibular joints. 43-45 benefits and risks. ‡ CDC/TMD: Clinical diagnostic criteria for temporomandibular disorders. § TMJ: Temporomandibular joint. It may be argued that ¶ κ Value: 0-0.2, no reliability; 0.2-0.4, poor reliability; 0.4-0.6, fair reliability; 0.6-0.8, good reliability; since only a low per0.8-1.0, excellent reliability. centage of the general population seeks treatment for symptoms of disk displacement and symptoms within 2.5 years, one-third had because asymptomatic patients who are incorimproved, and one-quarter continued to be symprectly diagnosed with disk displacement may tomatic. The authors concluded that this knowlincur unnecessary and potentially damaging edge would be valuable for treatment planning and treatment, lower sensitivity levels for an increase that the use of Wilkes’ classification system,51,52 in specificity may be used for this disorder so that which was based on both clinical and MRI observafalse-positive diagnoses can be avoided.46-48 tions, may be the best predictor of outcome. From a methodological point of view, etiology, As the CDC/TMD system is oriented mainly prognostic statements and implications for treattoward epidemiologic applications, the criteria ment are considered to be the main indicators for were established to not require imaging. Instead, the utility of a diagnostic system.49 While there is a they were based more on a description of observlack of knowledge regarding etiology, Kurita and able findings that appear to cluster together than colleagues50 have provided data for prognosis. In on underlying etiologic mechanisms. their prospective cohort study of the course of Further studies may be warranted to verify untreated symptomatic TMJ disk displacement that CDC/TMD-related disorders truly represent without reduction, they followed 40 patients for a distinct natural entities showing decisive differperiod of 2.5 years. The results indicated that ences in terms of prognosis and treatment approximately 40 percent of patients were free of outcome.3 JADA, Vol. 133, April 2002 Copyright ©2002 American Dental Association. All rights reserved.

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CONCLUSION

We conducted this prospective, double-blind study to determine whether applying the specific CDC/TMD diagnosis of TMJ ID type III would demonstrate good agreement with diagnoses obtained by MRI. Our study of the CDC/TMD system has failed to prove that the subgroup ID type III is a valuable predictor of MRI-related diagnosis of TMJ disk displacement without reduction. In the absence of biological gold standards or definitive diagnostic procedures to classify patients who have TMD in a way that is consistent with the CDC/TMD system, validation of diagnostic entities within the CDC/TMD system would involve the investigation of cross-sectional and longitudinal evidence to determine the homogenity of the classified groups, including risk factors, history and response to treatment.53 ■ Dr. Emshoff is an associate professor, Department of Oral and Maxillofacial Surgery, Höhenstraße 5, 6020 Innsbruck, Austria, e-mail “[email protected]”. Address reprint requests to Dr. Emshoff. Dr. Brandlmaier is a research fellow, Department of Oral and Maxillofacial Surgery, University of Innsbruck, Austria. Dr. Bertram is a consultant, Department of Oral and Maxillofacial Surgery, University of Innsbruck, Austria. Dr. Rudisch is a consultant, Department of Magnetic Resonance Imaging and Department of Radiology, University of Innsbruck, Austria. 1. Truelove EL, Sommers EE, LeResche L, Dworkin SF, Von Korff M. Clinical diagnostic criteria for TMD: new classification permits multiple diagnoses. JADA 1992;123(4):47-54. 2. Widmer CG, Huggins KH, Fricton J. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations, and specifications, critique, III—examination and history data collection. J Craniomandib Disord 1992;6:336-45. 3. Ohrbach R, Stohler C. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations, and specifications, critique, I—review of the literature, current diagnostic systems. J Craniomandib Disord 1992;6:307-17. 4. Clark GT, Carter MC. Electromyographic study of human jawclosing muscle endurance, fatigue and recovery at various isometric force levels. Arch Oral Biol 1985;30:563-9. 5. van Spronsen PH, Weijs WA, Valk J, Prahl-Andersen B, van Ginkel FC. Comparison of jaw-muscle bite-force cross-sections obtained by means of magnetic resonance imaging and high-resolution CT scanning. J Dent Res 1989;68:1765-70. 6. Emshoff R, Bertram S, Strobl H. Ultrasonic cross-sectional characteristics of muscles of the head and neck. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:93-106. 7. Tasaki MM, Westesson PL, Raubertas RF. Observer variation in interpretation of magnetic resonance images of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 1993;76:231-4. 8. Tasaki MM, Westesson PL, Isberg AM, Ren YF, Tallents RH. Classification and prevalence of temporomandibular joint disk displacement in patients and symptom-free volunteers. Am J Orthod Dentofacial Orthop 1996;109:249-62. 9. Tasaki MM, Westesson PL. Temporomandibular joint: diagnostic accuracy with sagittal and coronal MR imaging. Radiology 1993;186: 723-9. 10. Dworkin SF, LeResche L, DeRouen T. Reliability of clinical measurement in temporomandibular disorders. Clin J Pain 1988;4:89-99.

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