Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2010 37; 481489

Commentary

JOR-CORE recommendations on rehabilitation of

temporomandibular disorders
B. CAIRNS*, T. LIST, A. MICHELOTTI, R. OHRBACH & P. SVENSSON

Faculty of

Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada, Department of Stomatognathic Physiology, Faculty
of Odontology, Orofacial Pain Unit, Malmo University, Malmo, Sweden, Department of Oral, Dental and Maxillo-Facial Sciences,
Section of Orthodontics and Clinical Gnathology University of Naples Federico II, Naples, Italy, Department of Oral Diagnostic Sciences,
University at Buffalo, Buffalo, NY, USA and Department of Clinical Oral Physiology, School of Dentistry, Aarhus University, Aarhus C,
Denmark

Introduction
In the long history of temporomandibular disorders
(TMD), the term rehabilitation has been often
associated with occlusal rehabilitation indicating a
specific philosophy in which occlusion is the crucial
factor for TMD and that intervention on the occlusion
could cure the problem. In this paper, the term
rehabilitation is used to denote any medical, physical,
or psychological treatment which brings or restores an
individual to a normal or optimal state of health, and
this revised concept therefore significantly broadens the
scope of rehabilitation of TMD. The purpose of the JORCORE in Siena, 2009 was to critically examine the
current state-of-the-science in the field of TMDs. This
lead to four extensive reviews (14) and the present
summaries and recommendations for future research
into rehabilitation of TMDs.

Pathophysiology of TMD
State-of-the-science
The pathophysiology of temporomandibular disorders
(TMD) is complex and involves several mechanisms
discussed in Cairns (1). The principal symptom of TMD
that causes sufferers to seek medical care is pain in the
temporomandibular joint (TMJ) and or masticatory
muscles. Degenerative changes in the TMJ likely
underlie pain in only a subgroup of patients with TMD
and consequently there is often a poor correlation
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between the severity of pain complaints and pathological changes in joint and muscle tissues. It has been
demonstrated that some patients with TMD appear to
have altered central nervous system pain processing and
deficits in their ability to recruit endogenous analgesic
mechanisms; collectively, these two central processes
likely contribute to the development of chronic pain in
certain individuals. Recent findings suggest that the
propensity to develop chronic craniofacial pain may also
result from genetic variability that leads to altered levels
of neurotransmitters implicated in the activation and
modulation of pain pathways. Stress reactivity, which
may exert significant modulatory effects on pain
processing, is recognized as an important factor for both
the development and maintenance of pain in TMD and
other chronic pain conditions. There is a greater
prevalence of TMD amongst women, possibly related
to sex hormones and in particular oestrogen, although
how different sex hormones promote (or protect)
against TMD pain is unknown and therefore remains
an area of active research. Unfortunately, the specific
mechanisms that underlie TMD-related pain in the vast
majority of patients with TMD remain enigmatic.

Recommendations
The pathophysiology of TMD and its associated pain
clearly requires a sound foundation of scientific knowledge, particularly with regard to its pathogenesis to
permit the development of more rational and biologically based approaches to diagnosis and treatment, but
doi: 10.1111/j.1365-2842.2010.02082.x

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B . C A I R N S et al.
despite extensive investigations, this has not yet been
achieved. One area of scientific study that might bear
fruit in this regard is the determination of predisposing
factors for the development of TMD. For example, there
are a number of interesting polymorphisms of genes that
have been or may be associated with the development of
chronic pain conditions. Catechol-O-methyl-tranferase
(COMT) is one such gene gene product that has received
much attention, while other possible candidates include
serotonin transporters and oestrogen receptors which
need to be characterized further. Other potential biomarkers of TMD pain could include neuropeptides and
neurotransmitters such as calcitonin gene-related peptide (CGRP) and serotonin. Large population-based
prospective studies of patients with TMD and healthy
controls, such as the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study currently
being supported by the National Institute of Dental and
Craniofacial Research in the US, will be necessary to
screen for potential markers. Such studies, which focus
on putative risks factors, will also be required not only to
determine whether predictive markers are reliable but
also to define possible mechanisms that regulate potentiate pain. Furthermore, influence of stress and stress
hormones on nociceptive processing and clinical manifestation of TMD pain need to be better understood. It
will not be possible to employ rational and biologically
based treatments for TMD-related pain until these
mechanisms are defined more clearly and precisely than
they are now. This should lead to much more effective
means for treatment and possibly prevention of TMDrelated pain and dysfunction.

Orthodontics, occlusion and TMD

State-of-the-science
The current literature does not support any strong
associations between occlusal variables and TMD or any
significant beneficial or detrimental effects of orthodontic interventions on manifest TMD pain (2). Two
caveats, however, need to be recognized.
First, there is lack of specificity regarding the definition of occlusion and malocclusion. From a clinical
point of view, malocclusion could be any occlusion in
which the structural characteristics are different from
those established for a theoretically ideal occlusion.
Although ideal is difficult to define, a definition is
undoubtedly necessary if rational treatment goals are to

be established. It is also critical to recognize that even if

ideal has no bearing on what is normal or typical in
terms of what is necessary for health, reconstruction of
teeth (and supporting structures) according to ideal
standards should be a target of treatment if treatment is
indicated for other reasons, given that the boundary of
what constitutes clinically acceptable is even harder to
define. By extension, even if the prefix mal means
bad or ill, the term malocclusion does not necessarily imply that such an occlusion is non-physiologic
or that therapy is indicated.
Second, it is important to recognize that the term
TMD has been used, and still is used, very differently
in the published literature; for example, the criteria
used to denote presence or absence of TMD vary.
Indeed, TMD is a very general term that defines a wide
group of clinical entities (5), each with quite different
and mostly unknown aetiology and pathophysiology
(1) that only share in common the clinical features of
producing pain and or functional limitation in the
masticatory apparatus. Therefore, research protocols
should continue to investigate well-defined subtypes
without merging pain, joint sounds and or mechanical
dysfunction as though those symptoms necessarily
represent a single disorder.

Recommendations
While the current literature clearly supports the
absence of a relationship between occlusion and TMD,
definitional problems warrant further exploration of
possible associations between occlusion and TMD. This
recommendation is not made to suggest that such an
association exists, but rather it is made in the interest of
adhering to the principles of good science: methodological problems that may underlie the absence of
proposed relationships deserve further exploration.
To pursue further exploration of any possible relationship between occlusion and TMD, three developments are needed: (i) the boundary between acceptable
versus pathologic occlusion needs to be much better
delineated; (ii) the existing occlusal variables that have
already received much attention in published research
need to be augmented by additional factors pertaining to
the occlusion; and (iii) subtypes of TMD, which may
have greater potential to be affected by structural factors,
need to be defined based on mechanisms by which the
putative structural factors would affect the subtypes and
why specific subtypes might be more at risk.
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It is notable that most research regarding occlusion
and TMD has been limited to structural characteristics
associated with purely static occlusion (e.g. Angles
classification) or with pre-defined aspects of articulation
(e.g. so-called balancing interferences), assuming that
there is necessarily some measurable functional correlate or consequence of the identified characteristic. As
more specific recommendations for further exploration,
four directions are suggested. The first involves true
dynamics of how structure and function interrelate
(e.g. mastication where a bolus of food prevents actual
tooth contact for the most part, or parafunctional
behaviours involving direct toothtooth contact) which
are poorly understood and clearly deserve more
research to understand the relative contributions of
structure and functional patterns to TMD onset or
maintenance.
The second direction involves symptom perception
associated with occlusal structures. Based on research
in other areas of chronic pain (e.g. back pain), cognitive
(e.g. catastrophizing), attentional (e.g. hypervigilance)
and perceptual (symptom amplification) factors clearly
contribute to psychophysiologic reactivity, treatment
seeking and perpetuation of the condition. Of these,
one factor in particular, hypervigilance a state in
which an individual, possibly because of a combination
of predisposing genetic, psychosocial and environmental factors, is exceedingly aware of the sensory experience associated with a part of the body merits
investigation in association with occlusal variables.
Hypervigilance is hypothesized to account for reported
outcomes of occlusal treatment in patients with TMD
where symptoms associated with the occlusion and, in
particular, any modifications performed on the occlusion, independently of its anatomical or functional
status, are predominant. Research and better understanding of hypervigilance as a perceptual habit in
which attention is focused on sensations of a particular
type with subjective amplification of perceptions will be
needed. It can be speculated that hypervigilance,
together with other psychological states such as anxiety
or catastrophizing, could be a risk factor in patients with
TMD when the therapeutic management includes a
modification of the occlusion. Any alteration of the
existing occlusal pattern (even if minimally invasive)
may, especially in these patients, trigger a bodily
distress disorder (as has been termed in the back pain
area), e.g. an occlusal dysesthesia disorder leading to
further distress.
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A third direction warranting more research is the

adaptive capability or resilience of the individual which
could influence the definition of normal as well as the
results of any typical occlusal interventions provided to
patients with dental restorative needs (or perhaps
aesthetic needs) and who also have a TMD with, we
assume, an external aetiology (e.g. trauma to the jaw).
One testable hypothesis is that TMD causes irreversible
degenerative alterations in the masticatory apparatus
and, consequently, the system reacts with adaptive
changes, in some cases also irreversible, in an attempt
to regain the functional equilibrium. In this clinical
situation, any occlusal modification procedure performed in these patients, even if appropriately indicated
for occlusal rehabilitation purposes and technically
correct, may exceed the adaptation capability of the
system, the patient, or both, compromising the clinical
status of the condition. Adaptation capability is important for all of dentistry, in that procedures regarded by
the profession as routine may not be routine for a given
individual, and consequently occlusal modification
performed as part of an extensive plan of restorative
treatment may exceed that capability and trigger the
onset of an iatrogenic TMD.
A fourth direction is the relation between occlusal
characteristics and muscle activity. Hyperactivity of the
masticatory apparatus may include both functional
(chewing habitual food, chewing gum, tobacco, sun
seeds) and parafunctional oral habits, including but
not restricted to non-functional tooth contacts; clenching and grinding of the teeth; biting of objects such as
nails, fingers, or lips; and non-tooth contact behaviours
such as bracing or thrusting the jaw. Carefully designed
research projects are still needed to evaluate whether
patients with waking-state or sleep-state non-functional tooth contacts are at higher risk of developing
particular subtypes of TMD; what has not been considered with this well-known question is whether the
effects of these parafunctional behaviours occur perhaps in an occlusal-dependent manner. The current
literature does not support the belief that occlusion per
se influences the occurrence of non-functional tooth
contacts; however, the interaction between occlusal
variables and specific patterns associated with parafunctional activity should be evaluated to determine
(i) the boundaries of normal for occlusal status;
(ii) whether occlusal modifications in patients with
TMD are more risky if the patient already has or is
independently at risk for increased muscle activity

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related to parafunctional behaviours; and (iii) whether
otherwise non-TMD patients with increased muscle
activity (e.g. the individual with chronic asymptomatic
sleep-bruxism) are at higher risk of developing a TMD
when undergoing an occlusal modification procedure.
In conclusion, there is a need for critical thinking and
careful planning of well-designed studies before the
associations between occlusal variables and TMD are
attempted to be (re)examined.

Reviews of management of TMD pain

State-of-the-science
It is difficult for anyone to stay current with the
constant growth of new scientific information and
professional recommendations and to simultaneously
evaluate the reliability, validity and applicability of
published results, and it is particularly difficult for fulltime clinicians to do this (3). Dentists must find a way
to manage this expanding mass of new knowledge a
way to filter and compile the information - so that it is
clinically useful. Evidence-based medicine (EBM) is the
integration of (i) best research evidence with (ii) clinical
experience and (iii) patient values. These three elements are essential to integrate to achieve optimal
clinical outcome and quality of life for the patient.
Clinicians and patients form a diagnostic and therapeutic alliance that has the potential to optimize clinical
outcomes and quality of life.
Our aim here is to focus on how EBM needs to be
integrated in clinical practice, research settings and
undergraduate teaching and to discuss benefits and
limitations of clinical trials and systematic reviews
(SRs).
EBM in clinical and research settings Two important
elements in EBM, research evidence and clinical
expertise, are nicely defined by Sackett et al. (6):
(i) Best research evidence means clinically relevant
research emerging not only from the basic sciences but
also from patient-centred clinical research regarding the
accuracy and precision of diagnostic tests (including the
clinical examination, prognostic markers, and the efficacy and safety of therapeutic, rehabilitative and
preventive regimens) and (ii) clinical expertise is the
ability to use our clinical skills and past experiences to
rapidly identify each patients unique health state and
diagnosis, their individual risks and benefits of potential

interventions, and their personal values and expectations.

In EBM, evaluation of a patient and subsequent
treatment decisions are a combination of (i) the
available literature and investigations, (ii) clinical
experience and (iii) the specific needs of each patient.
It would seem obvious that in clinical practice, the EBM
approach should benefit the patient. The question,
however, is whether busy clinicians are prepared to use
all three elements? How does the shortage of consistent
scientific evidence affect implementation of treatment?
How eager are clinicians to apply new knowledge and
skills in clinical practice?
One limitation to the practice of EBM is the generalizability of studies [e.g. randomized clinical trials
(RCT), casecontrol studies] to the typical clinical
setting. Studies often have very specific inclusion and
exclusion criteria, which sometimes do not capture the
typical patient. Therefore, the generalizability from an
RCT to the patient in the clinic may be unclear. Some
instruments used extensively in research, such as the
RDC TMD, are considered by some practitioners as
time consuming and not always practical to use in a
busy clinical practice. Standardized screening examination procedures and short-form self-report instruments
are a useful alternative approach for transferring to
clinical practice some of the core principles used in
clinical research.
SRs, because they provide the best available research
evidence for a specific issue, can be useful for clinicians
and patients. Recommendations from SRs are not
always conclusive, however, and consequently, SRs
are likely to be most useful in excluding treatment
strategies that are highly unlikely to be beneficial. This
knowledge can be used in clinical decision-making and
for educating the patient. One limitation is that clinicians who are not trained in EBM would have problems
advising and disseminating this information to the
patient because it requires a significant shift in how one
uses evidence and scientific logic.
EBM in undergraduate education The focus in EBM
teaching has always been a patient-centred clinical
situation. EBM emphasizes interactive, learner-centred
activities for self-directed life-long learning. In undergraduate education, the major benefit of EBM is that
students are taught how to think critically and ask
themselves questions. One limitation is that because
not all teachers are trained in evidence-based medicine,
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EBM is taught as a separate subject and not integrated
into the curricula in the dental schools.
Does EBM improve outcome for patients? In the medical
field, studies have reported that those patients who
receive evidence-based therapies have better outcomes
than those who do not. Although no RCT that focuses
on that specific issue applied to TMD has been
published, it is reasonable to assume that the findings
from such studies in other areas are applicable to TMD,
such that we can suggest that EBM does improve
patient care for TMD. Economic conditions and medical insurance policies, however, may vary from
country to country and profoundly influence the
choice of treatment and its extensiveness. The treatment, as identified through EBM, is not always
available to patients.
The third important element in EBM is patient values
and it was defined by Sackett et al. (6) as the unique
preference, concerns and expectations each patient
brings to a clinical encounter and which must be
integrated into clinical decisions if they are to serve
the patient. So the individual perspective, chief complaint, lifestyle, culture and expectations of each patient
must be considered in selecting a particular treatment
strategy.
Methodological concerns in clinical trials Common problems in study design in several studies include small
sample size, randomization, blinding and unreliable or
non-patient-oriented measures. The results of investigations are not always generalisable because the
patients condition, diagnosis and treatment differ from
the features of patients and treatments normally found
in clinical practice. Most studies relate their results to
quantitative measures such as pain intensity, pain
frequency, or medicine consumption, all of which are
commonly accepted if not recommended therapeutic
end-points for clinical trials but which are not necessarily the variables of greatest concern to a given
patient. Qualitative research would be an alternative
approach. If quantitative research methods best measure the impact of TMD pain in a group, it may be
that qualitative research best describes the impact of
TMD pain in an individual. The aim of qualitative
research is to understand the phenomena in natural
rather than experimental settings, with an emphasis
on understanding the experiences and values of our
patients.
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Benefits and limitations of a SR SRs are valuable because

they provide a concise and easily read overview for
both the clinician and researcher of the literature on a
specific issue, and it provides a pool of readily identified
quality studies. An SR can be used to educate and guide
patients so that they more easily understand their
condition and will adhere to treatment. However, the
value of an individual SR cannot exceed the value of
the studies being reviewed: if there are inherent
limitations in the cited RCTs (e.g. generalizability
problems), conclusions from the SR will be similarly
limited. Additionally, if conclusions are mixed, the
clinician will probably have to read the individual
studies contained in the SR because one factor determining the applicability of various research findings to
a particular patient is the match in characteristics
between the given patient and the subject pool of the
particular study. Also, more recent studies or studies
that were inadvertently not included in the SR could
affect the recommendations.
Benefits of SRs include the time they save by focusing
on only quality studies and the possibility to exclude
therapies that lack success or are harmful.

Recommendations
Research methods which allow patient-specific tailoring of treatment outcomes are needed. Such methods
would weight those outcomes that are important for a
particular patient more heavily than outcomes that
are less important for that patient. For example, if
patient #1 thought that better quality sleep was
highly important, sleep measures would have higher
weight in her outcome data than other measures that
she considered less important; if patient #2 thought
that pain-related affect was most important, this
outcome measure would be weighted more highly
than others. Such an approach might allow for
research summaries that consider whether the intervention generally provided improvement in symptom
areas that were most important for patients, even
if different patients weighted different outcomes
differently.
To minimize mistakes in study design, CONSORT
recommendations should be followed by the researcher
and required by all journals that publish clinical trials.
Basic science studies should be designed in a manner
likely to make them translatable into at least clinical
research if not clinical practice. In a clinical research

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setting, more evidence regarding accuracy and precision of diagnostic tests is needed. In addition, more
evidence is needed about TMD and the impact that
TMD exerts on patients daily lives (see also Section on
Disability).
Knowledge regarding patient preferences with respect to treatments and the determinants of treatment
compliance is currently limited. A qualitative methodological approach would probably shed some light
on this issue and improve patient outcome measures.
However, medical journals often will not publish
qualitative studies because of reviewers having
insufficient training and appreciation of qualitative
methods.
In a research setting, it is important that the assessment of treatment outcomes include multiple domains
which together can capture a more comprehensive
picture of the pain condition. For patients with TMD
with chronic pain, IMMPACT recommendations
include these domains: pain; physical functioning;
emotional functioning; participant rating of improvement and satisfaction with treatment, symptoms, and
adverse events; and participant disposition (7). These
domains are being modelled within the revision to the
RDC TMD [see also Ohrbach et al. (8)].

Disability
State-of-the-science
Limitation and disability is a major issue in TMD, and
these concepts coupled with pathophysiology and
impairment are collectively referred to as disablement (4). And, as Michelotti and Iodice (2) and Ohrbach
(4) have shown, these concepts apply to other areas of
dentistry as well. However, it seems to be a global
challenge to incorporate the concept of disablement into
dental education and dental clinical practice consistent
with published descriptions of the problem. In addition,
there is a lack of appreciation of the consequences of not
addressing disability within dentistry (9). Given the
magnitude of this challenge, the most streamlined
approach for ready integration of disablement assessment into everyday clinical practice requires respect for
and adherence to several key principles:
1 Clinical practice is challenging with respect to both
technical skills and clinical time management. At
present, management of patients biomedical expectations of dental treatment can be difficult. Transforming

Initial or returning (new complaint) patient

(Captive time in a waiting room)
Patient completes screener for distress and social disability
Clinical evaluation:
History intervieaw for yellow flags
Review screener responses and scores

No

Significant yellow flags

warrant immediate concern ?
Yes

Proceed/continue treatment
Scheduled review (24 weeks)
(rule-out red flags, monitor yellow flags)

Red flags :
investigate
or refer

Yes

Can provider
address positive flags?
No

Making good progress

Yes

Refer for specialist

consultation*

No
Rule-out red flags
Re-evaluate 8 yellow flag areas
Can provider
address positive flags?

No

Yes
Modify treatment
Scheduled review (24 weeks)
(rule-out red flags, monitor yellow flags)
Further evaluation or refer*

* Minimal assessment protocol for

limitation and disability
To be used in further evaluation by the
treating clinician (as appropriate) or
by referral for specialist consultation:
pain
functional limitation
pain-related disability
depression
anxiety
non-specific (co- morbid) physical
symptoms
oral HR-QoL

Fig. 1. Flow chart for routine incorporation of disablement

assessment into general clinical practice and specialist referral.

the practitioners practice to a biopsychosocial orientation will, therefore, be even more demanding of skill
and time. The question must therefore be posed as to
how to train dentists in this skill?
2 Any attempted assessment of disablement must be
pragmatic and must transparently fit into any general
dental setting.
3 The outcome of the disablement assessment must be:
unambiguous to the general dental practitioner; practical within the context of an ongoing dental setting;
and useful to the patient and the practitioner.
A model already in use for assessing back pain
which incorporates the concept of red flags and
yellow flags (10)1 to make disablement assessment a
key part of primary medical care may have merit for
providing a framework for assessing disablement in
1

Red flags identify potentially serious conditions such as pain that

awakens the patient from sleep, drug addiction, or suicidal ideation
that have immediate mortality or morbidity. Yellow flags identify
psychosocial barriers to reasonable treatment response.
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everyday clinical practice. The flag type of system
should reduce the burden of such assessment within
dentistry, thus ensuring that all patients in a given
setting receive the same level of initial screening for
limitation and disability. The screening and resultant
presence or absence of flags would then determine
whether or not a formal minimal assessment protocol
for limitation and disability was indicated, thereby
reducing the number of formal assessments that
routine day-to-day dentistry might demand (see
Fig. 1).

Recommendations
For implementing routine assessment of disablement
status of individuals being evaluated and treated in
dental settings, a stepped approach comprised of
screening followed, as needed, by more formal assessment is recommended. A stepped approach is increasingly regarded as the most efficient method for
collecting context-relevant information. Based on evidence from other areas of medicine, the screening stage
should focus on the identification of yellow and red
flags. Clinical data pertaining to flags can be easily
obtainable in routine clinical dentistry using two
methods for screening: (i) a standardized self-report
instrument for information not readily obtained via
other methods and (ii) clinical interview (history) for
complaint-relevant information. The outcome of such
information acquisition should then denote specific
courses of action.
The self-report instrument should examine, in no
more than 20 items, distress and social disability.
Distress and social disability were selected as useful
screening constructs for disability as it was envisioned
that they would capture significant elements of disability and handicap. A threshold, to be determined, in the
self-report instrument would indicate whether it was
necessary or appropriate (or not) to proceed with
completion of the minimal formal disability assessment
set to more accurately examine the level of disability of
the patient in question. This is believed to be a
pragmatic approach to the problem of disability assessment for the busy clinician, as not all patients will need
a full disability assessment for every complaint. The
distress portion of the instrument would also assess for
significant problems such as suicidal ideation. The
distress and social disability screening instrument needs
to be further developed.
2010 Blackwell Publishing Ltd

The second method of determining flags is through

the clinical interview (history). Implicit in this method
is the need for additional educational and clinical
training so that dental practitioners are comfortable
and well versed with core psychosocial issues in a
history. Some of the flag areas that might be associated
with history-taking and might merit further investigation are:
1 Chronicity. Determine the chronicity of the complaint;
chronic pain, for example, is associated with greater
likelihood of clinically significant depression and alterations in central nervous system processing of nociceptive stimuli.
2 Functional limitation. Assess functional limitation
status with regards to chewing, jaw mobility and use
of the jaw for other functions; these areas would be
explored via simple interview questions to determine
whether the individual has such problems, and the
expected form of the responses need only be binary
(yes, no) but could obviously be elaborated. For
example, pain associated with a temporomandibular
disorder should be accompanied by problems in jaw
function as a minimum.
3 Discrepancy in findings. Determine whether there is a
discrepancy between reported symptoms versus observed findings; such discrepancies can point to significant other factors contributing to the individuals
symptom report.
4 Overuse of medication. Review medication history for
prolonged or excessive use of opiates, benzodiazepines,
alcohol, or other drugs.
5 Inappropriate behavior. Observe for behaviour inappropriate to the complaint; such behaviour can be
explicit or implicit.
6 Inappropriate expectations. Determine whether the
patients expectations regarding character or outcome
of treatment are unrealistic or inappropriate; such
expectations on the part of the patient can point to a
number of underlying problems that typically interfere
with good health care delivery. Note that providers may
also have unrealistic or inappropriate expectations
about the presumed outcome of recommended treatment but that is a problem that needs attention
elsewhere.
7 Inappropriate responsiveness to (prior) treatment. Determine whether prior treatment has been associated with
inappropriate response in the patients symptoms; failed
prior treatments do not bode well for the currently

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planned therapy. This yellow flag is also assessed by
the provider at each follow-up visit of his her own
treatment.
8 Identify red-flags from self-report screener. Suicidal
ideation is one symptom within this portion of the
evaluation that is a red flag and requires immediate
action. Other possible red flags warrant further
investigation and will be determined, for the most
part, by the final content of the screener as well as by
evolving standards for taking a history of pain
complaints as well as by reviewing the medical
history.
The two methods for determining flags are implemented into a modification of the care system for a
dental patient as shown diagrammatically in Fig. 1.
While the minimal assessment procedures for screening
via identification of yellow and red flags should
contain, as bulleted in Fig. 1, assessment of multiple
areas, it remains nevertheless lean, efficacious, efficient, easily integrated into procedures already performed, and highly sensitive.

Implementation in clinical settings

In reference to Fig. 1, stepped minimal disability
assessment that includes administration of the standardized screening instrument, interview questions,
interpretation of psychosocial yellow flags (and
biomedical red flags) and appropriate review at
subsequent office visits would proceed as follows. A
new patient, or a returning patient with a new
complaint, completes the self-report distress and social
disability screener and it is scored prior to the
dentists exploration of the presenting complaint.
The history-based yellow flags are explored during
the history of complaint. These and any further
positive flags are noted in the patients record. The
number of yellow flags needed to trigger the use of
the formal minimal disability protocol is not yet
established, but clearly descriptive information associated with any positive yellow flags should enter into
clinical decision-making and possibly lead to stepped
progression of the evaluation. Moreover, it would
seem intuitive that any red flag should result in
immediate attention for further investigation and or
referral.
At the first return visit progress via either symptom
status or other measures could be assessed, and if the
patient is flagged as having an inappropriate response to

the treatment provided, then the provider should

reconsider the diagnosis, treatment, or both. If inappropriate response to treatment is flagged at this visit,
the provider would also revisit all yellow flag screening
items as well as exclude red flags. One more cycle of
treatment could then be considered. If treatment now
progresses well, the provider should continue with
treatment and continue to monitor for red and yellow
flags.
If the second cycle of treatment does not proceed
well, further diagnostic evaluation in the area of
disablement is indicated; certainly other medical
evaluation should be considered at this stage as well
in that poor progress with treatment could be because
of either medical or psychosocial factors, and each
should be further investigated at this stage without
neglecting the other. This further investigation of
psychosocial factors would be performed through
application of the minimal assessment protocol for
limitation and disability. The initial provider can
pursue this assessment, if prior training and experience provide the necessary clinical skills, or the
provider could refer the patient at this juncture to a
specialist who has that training. These constructs
would then be assessed by the specialist at the
beginning of evaluation in lieu of using the distress
and social disability screener.
These recommendations, however, form a new perspective that requires testing to obtain evidence for its
validity and utility. Therefore, these recommendations
entail: (i) instruments and instrument sets must be
developed and thoroughly tested and (ii) extensive field
testing of the practicality of the proposed protocol for
assessing disability in dentistry must take place. This
work is critical to ensure that any large scale changes
made in the practice of clinical dentistry are evidence
based and robust.

Conclusions
The present summaries and recommendations are
based on the extensive reviews (14) and discussion
within the four working groups during the JORCORE. Overall, these recommendations are based on
current understanding of the published dental literature, particularly as it relates to TMD pain, and
provide a framework to move rehabilitation of not
only patients with TMD but all dental patients
forward.
2010 Blackwell Publishing Ltd

JOR-CORE 2009 RECOMMENDATIONS

Acknowledgments

References

The sponsors Wiley-Blackwell and Medotech Aps are

thanked for their financial support to the JOR-CORE
which would not have been possible without the
financial aid.
The authors, who are listed in alphabetical order,
extend appreciation to the workgroup members for
their valuable input and contributions to previous
versions of this recommendation. The workgroup
members were:

1. Cairns BE. Pathophysiology of TMD pain - basic mechanisms

and their implications for pharmacotherapy. J Oral Rehabil.
2010;37:391410.
2. Michelotti A, Iodice G. The role of orthodontics in temporomandibular disorders. J Oral Rehabil. 2010;37:411429.
3. List T, Axelsson S. Management of TMD: Evidence from
systematic reviews and meta-analyses. J Oral Rehabil. 2010;
37:430451.
4. Ohrbach R. Disability assessment in temporomandibular disorders and masticatory system rehabilitation. J Oral Rehabil.
2010;37:452480.
5. Dworkin SF, LeResche L. Research diagnostic criteria for
temporomandibular disorders: review, criteria, examinations
and specifications, critique. J Craniomandib Disord Facial Oral
Pain. 1992;6:301355.
6. Sackett D, Straus S, Ws R, Rosenberg W, Haynes R. Evidencebased medicine. How to practice and teach EBM. Edinburgh:
Churchill Livingstone, 2000.
7. Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen
MP, Katz NP, et al. Core outcome measures for chronic pain
clinical trials: IMMPACT recommendations. Pain. 2005;113:
919.
8. Ohrbach R, List T, Goulet J-P, Svensson P. Recommendations
from the International Consensus Workshop: Convergence on
an Orofacial Pain Taxonomy. J Oral Rehabil. 2010; In press.
9. Locker D. Measuring oral health: a conceptual framework.
Community Dental Health. 1987;5:318.
10. New Zealand Guidelines Group. New Zealand Low Back Pain
Guide. 2004. Wellington, New Zealand.

Pathophysiology workgroup members

Iva Alajbeg (Croatia), Altair Del Bel Cury (Brazil), Sibel
Dincer (USA), Malin Ernberg (Sweden), Gary Heir
(USA), Adriaan Klitsie (Netherlands), Howard
Tenenbaum (Canada).

Occlusion and orthodontic workgroup members

Taro Arima (Japan), Jose Luis de la Hoz (Spain),
Susanne Elmasry Ivanovic (Sweden), Malvin Janal
(USA), Pinar Kursoglu (Turkey), Tomohiro Tanosoto
(Japan), Ephraim Winocur (Israel), Luo Xiaoping
(China).

Systematic review workgroup members

Jari Ahlberg (Fin), Maria Clotilde Carra (Italy),
Fernanda Foat (Brazil), Nikolaos Giannakopoulos
(Germany), Ebru Ispirgil (Turkey), Karen Raphael
(USA), Claudia Restrepo (Columbia), Olcay Sakar
(Turkey).

Disability workgroup members

Justin Durham (UK), Anat Gavish (Israel), Jordi
Martinez-Gomis (Spain), Yoshihiro Tsukiyama (Japan),
Wataru Yachida (Japan).

2010 Blackwell Publishing Ltd

Correspondence: Svensson P, Department of Clinical Oral Physiology,

School of Dentistry, Aarhus University, 8000 Aarhus C, Denmark.
Email: psvensson@odont.au.dk

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