Quality Resource Guide l Temporomandibular Disorders 4th Edition 7 www.metdental.com joint and muscle conditions. To date, it is the only classification system that incorporates standardized and reliable self-report questionnaires, clinical examination procedures, scoring systems, and decision trees. Furthermore, no other system integrates biophysical diagnosis to a disability index that measures the impact that pain has on the patient’s behavior. A supplementation and extension of the DC/TMD, to include less common masticatory muscle and temporomandibular joint conditions, is the expanded DC/TMD. 111 This system incorporates thirty seven conditions that have operationalized diagnostic criteria. Another classification system known as the International Classification of Orofacial Pain (ICOP) 112 was developed in 2020. This classification system emphasizes the characteristics of the pain disorders rather than the anatomic location. Included in ICOP are TMD diagnostic criteria which have been adopted from the DC/TMD by including only painful TMD conditions. Additionally, ICOP incorporates a time component to diagnosis as well as distinguishing primary from secondary pain. To assist the clinician in the diagnostic process, a validated TMD screener has been developed which may be administered in either a short (three- item) or long (six-item) version. This psychometric instrument has excellent levels of reliability, sensitivity, and specificity thus supporting its usefulness in any clinical office setting. 113 Management Considerations Management of TMD/orofacial pain must be viewed on a case-specific basis. To achieve optimum outcomes, the practitioner(s) must address the specific pathophysiology. The traditional model of monodisciplinary management has proven to be effective in cases where definitive cause and effect relationships may be established. However, the multifaceted nature of these conditions, in combination with the associated features and comorbidities of recurrent and/or chronic pain, add a significant degree of complexity to management decisions and interventions. Utilization of multidisciplinary (imparts knowledge from different disciplines but stays within their boundaries - work performed by multiple members who work in the same field) and interdisciplinary (analyzes, synthesizes and harmonizes links between disciplines into a coordinated and coherent whole - work performed by team members from multiple specialties or disciplines) models of diagnosis and management encourages the integration of a management plan with input from a cadre of health practitioners (Table 1). 114,115 This approach will enhance outcomes by addressing physical, somatic, psychological, social, environmental, and behavioral factors in a well- orchestrated fashion. The goals of management include: 1) reduce or eliminate pain; 2) halt the disease process when possible; 3) normalize function; 4) improve quality of life; and, 5) reduce the need for long-term care. 116 Implementation of a multimodal strategy requires adherence to a biopsychosocial model by which the therapy team develops a complete and definitive diagnosis encompassing all physical and psychosocial factors. Goals must be established with regard to treatment duration, pain management approaches, patient involvement, and a plan for the patient to return to activities of daily living. Success is dependent on regular communication between all the team members. Conclusions TMD represents a multitude of conditions afflicting the masticatory region with implications that transcend anatomic and neurologic boundaries. TMDs are multifactorial in nature, encompassing both physical and psychosocial domains. Significant variability exists among patients indicating there may be predisposition in some cases. Scientific studies suggest the involvement of both peripheral and central mechanisms (sympathetic nervous system and immune system) which compromise the individual’s pain dampening (modulating) system, playing a major role in recurrent and chronic cases. Therefore, it is essential that a complete evaluation of the patient from historical, clinical presentation, and physical/psychosocial examination perspectives be accomplished. Finding all the components of TMD/ orofacial pain on a case-specific basis is necessary for a complete and accurate diagnosis, and effective management. Highlighting this suggestion, is a 400-page report from the National Academies of Sciences, Engineering, and Medicine (NASEM) entitled “Temporomandibular Disorders: Priorities for Research and Care”. 117 The aim of the report was to provide recommendations that would lead to improved health and well-being of individuals with TMDs. By following these approaches and initiatives we can hopefully achieve the goal stated by Liebeskind and Melzack: “By any reasonable code, freedom from pain should be a basic human right limited only by our knowledge to achieve it.” 118 Acknowledgement The first three editions of this Guide were co-authored by Henry Gremillion, DDS and Gary Klasser, DMD. Dr. Klasser reviewed and updated the material for the 4th edition.