Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) Pain Drawing: Survey of Use, Barriers, and Potential Modifications

Abstract

Background: The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) introduced the DC/TMD pain drawing to assess pain location and the presence of widespread pain, providing a valuable visual representation of a subjective experience. Using DC/TMD pain drawing is recommended for routine use in dental practice, especially for individuals experiencing TMD or orofacial symptoms. As a crucial component of DC/TMD for over a decade, there hasn't been a specific study examining its utilization in both clinical and research domains. Key inquiries include identifying potential challenges or barriers associated with its application to prevent healthcare providers from fully utilizing and benefiting from DC/TMD pain drawings in clinical and research settings.Aims: The primary aim of this study was to investigate the utilization of DC/TMD pain drawing and identify associated barriers. The secondary aim was to determine the necessity for and recommendations for modifying the current DC/TMD pain drawing. The last aim was to develop a new pain drawing with a visual representation of instructions based on findings from Aims 1 and 2 with the objective of enhancing pain location identification. Methods: This mixed-methods cross-sectional survey study was conducted using RED Cap© to address aims 1 and 2 completed in spring 2024. The first survey was purposively distributed to an estimated 500 current members of the American Academy of Orofacial Pain and the IADR-INFORM DC/TMD translations group. The second survey was purposively distributed to 62 individuals who have published or worked on pain drawings within the last 10 years and the IADR-INFORM DC/TMD translations group. Surveys including single, multiple-choice, and open-ended questions to collect different perspectives on using and improvement of DC/TMD pain drawing. Analyses included descriptive statistics, means, and standard deviations; the open-ended responses were summarized by the themes, and the frequency of unique individuals mentioning a theme was recorded. Results were compared between raters for agreement. Results: 49 participants completed Survey 1 and 21 completed Survey 2 (response rate=33.9%). Overall, Survey 1 had 45 participants (91.8%) familiar with the DC/TMD pain drawing. The most common three ways of using the DC/TMD pain drawing are to visualize specific pain locations (n=32, 65.3%), as a screening tool for pain(n=27, 55.1%), and to visualize pain referrals (n=23, 46.9%). The top three concerns with using the DC/TMD pain drawing are no digital version(n=27, 55.1%), patients do not accurately draw their pain locations(n=22, 44.9%), and anatomical locations are not detailed enough to differentiate pain location (n=17, 34.7%). The survey 2 study indicates nearly 72.0% agreement that some modification could improve the DC/TMD pain drawing, for our improvement suggestions, 71.4% agreed on a visual representation of instructions(n=15),66.6% agreed on adding a three-quarter view to replace the lateral views of the face(n=14), and 95.2% agreed to add a larger view of the back of the head(n=20). 52.4% agreed creating a new pain drawing should include pain characteristics(n=11), and only 23.8% (n=5) agreed with a color-coded system to represent pain quality. Based on the results of aim1 and 2, our research team developed a new version of pain drawing, which includes the additional enlarged front and back head view with the extension of neck region, bilateral ¾ face view, and the improved intraoral view by increasing the anatomical area, with a new page of visual instruction to help patients to draw all their pains on it. Conclusion: The DC/TMD pain drawing is being used by both clinicians and researchers despite barriers encountered, such as lack of digitalization/integration, concerns about accuracy, and desire for additional anatomical details. Using a priori team-developed suggestions and those from participants of this study, our research team has created and proposed a beta version of a derivative supplemental pain drawing with additional frontal, back of the head, three-quarter face, and extended neck views along with visual instructions to meet the needs of the stakeholders surveyed.