CoChat
Sign Up
Cited by 1Temporomandibular Joint DisordersFacial Trauma and Fracture ManagementMyofascial pain diagnosis and treatment

Algorithm for Temporomandibular Disorders With Osteopathic Manipulative Therapy: An Expert Consensus

Open access
De-La-Iglesia, Llanos, Bravo, Cristina, Justribó-Manion, Cristian, Montmany, Anna, Roman-Arias, Toni, Hue, Isabelle, Dugailly, P-M, Colasanto, Stefano +2 more·2025·Journal of Chiropractic Medicine
DOI 10.1016/j.jcm.2025.09.034PMC PMC12804032
Open this paper in CoChat — free account

Abstract

Objective: The purpose of this study was to create a consensus algorithm for the osteopathic approach to temporomandibular dysfunctions Methods: A conventional Delphi method of at least 3 rounds of questionnaires was carried out by a panel of experts to reach a consensus on a flowchart algorithm for the diagnosis and treatment of temporomandibular disorders with osteopathic manipulative therapy Results: During the 3 rounds, a total of 7 panellists participated. Consensus was reached on 182 items (70.54% = 182/258). The algorithm has a numerical code with which the direction of each option can be followed, and a color code that shows the classification of each of the items (anamnesis, examination, observation, referral, palpation and treatment). The algorithm begins with 4 main categories: psychological aspects, exclusion criteria, physical aspects, and other issues, which are further subdivided into specific items that will be addressed according to the findings obtained during the patient visit. Conclusion: This study created an algorithm for the osteopathic approach to temporomandibular dysfunctions.

AI snapshot

Written from the paper’s full text.

TL;DR

A 3-round Delphi consensus of 7 osteopaths from 5 countries produced a flowchart algorithm for osteopathic manipulative therapy in temporomandibular disorders. Consensus was reached on 182 of 258 items (70.54%) using a ≥70% agreement threshold.

Key findings

  • The Delphi process had no withdrawals and lasted 5 months; round-specific consensus was 95/118 items (80.5%) in round 1, 69/104 (66.3%) in round 2, and 18/36 (50%) in round 3. Items without consensus were discarded from the algorithm.
  • Overall, consensus was reached on 182/258 items (70.54%).
  • The final flowchart algorithm uses a numerical code to follow each option and a color code for item classification: anamnesis, examination, observation, referral, palpation, and treatment.
  • The algorithm begins with 4 main categories: psychological aspects, exclusion criteria, physical aspects, and other issues, which are subdivided according to patient visit findings; all experts approved the final result.

Methods

  • Conventional Delphi method with 3 rounds of emailed questionnaires; the panel comprised 7 osteopaths from different countries, selected for European-standard osteopathic training, postgraduate teaching in the orofacial region, and/or research in orofacial pain or TMDs.
  • Round 1 questionnaire was developed from a literature search in PubMed, CINAHL Plus, Scopus, Cochrane Library, and PEDro, limited to the last 5 years and human research; questions were mostly closed dichotomous items plus one open question, with opportunities to add options and references. Consensus was defined as ≥70% agreement.
  • Analysis used IBM SPSS 27.0, with mean values and standard deviations for demographic data and frequencies/percentages for item responses; reporting was guided by CREDES and COREQ.

Limitations

  • Stated: experts’ management of TMDs was quite different despite all working in osteopathy, leading to numerous contributions and more complex results than expected; participation was lower than anticipated despite no dropouts; and there is no universally accepted methodological guideline for applying the Delphi method in a more standardized manner, though the classic version was used.
  • Evident from the text: the panel was small (7 experts) and all were osteopathic clinicians and postgraduate teachers in the TMJ field, so the consensus reflects this specific expert group; the study did not clinically validate the algorithm or test patient outcomes; and the final algorithm and item details are placed in a supplementary file rather than fully reported in the main text.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.jcm.2025.09.034

Cites

38 of 38 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

3 of 13 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Findingown data

    In total, during the 3 rounds, consensus greater than 70% was obtained on 182 of 258 items (70.54%).

    “Consensus was reached on 182 items (70.54% = 182/258).”
    Quote in the paperSubstantial claim
  • Findingown data

    In the first round, consensus exceeding 70% was reached on 95 of 118 items (80.5%).

    “In the first round, there was a consensus exceeding 70% on 95 items out of 118 (80.5% = 95/118)”
    Quote in the paperNot a substantial claim
  • Findingown data

    In the third round, consensus was reached on 18 of 36 items (50%).

    “The third round, which consisted of the issues on which no consensus was reached in the first questionnaire, had a consensus on 18 of the 36 items (50% = 18/36).”
    Quote in the paperNot a substantial claim
  • Findingown data

    After Delphi rounds, consensus was reached on an algorithm for approaching temporomandibular disorders.

    “After Delphi rounds, consensus was reached on an algorithm for approaching TMDs.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: A panel of 7 osteopaths is sufficient to produce a valid expert consensus algorithm for the management of temporomandibular disorders with osteopathic manipulative therapy.
  • Findingown data

    In the second round, 69 of 104 questioned items had consensus of more than 70% (66.3%).

    “In the second round, where the questions that did not reach consensus and the new contributions were raised, 69 of the 104 questioned items had a consensus of more than 70% (66.3% = 69/104).”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 15
  • May combine two claims. 9

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The description of the Delphi method was developed with CREDES best practices.

    “The description of the Delphi method was developed with guidance on conducting and reporting Delphi studies (CREDES) best practices.29”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [29] Jünger, 2017, Guidance on conducting and REporting DElphi studies (CREDES) in palliative care: recommendations based on a methodological systematic review, Palliat Med source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The aetiology of temporomandibular disorders is multidimensional, involving biomechanical, neuromuscular, biopsychosocial and/or biological factors.

    “The aetiology of these dysfunctions has been found to be multidimensional. Within TMJ disorders, biomechanical, neuromuscular, biopsychosocial and/or biological factors may be involved.6”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [6] Chisnoiu, 2015, Factors involved in the etiology of temporomandibular disorders—a literature review, Clujul Med source

  • May combine two claims.

    Interpretationcitation

    The number of rounds needed to reach consensus was 3, which is within what is expected according to the review by Niederberger and Spranger.

    “In spite of this, the number of rounds needed to reach consensus was 3, which is within what is expected according to the results obtained in the review by Niederberger and Spranger,40, 41 who observed that for the most part, classic Delphi studies mostly invest between 2 and 3 rounds.”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [40] Niederberger, 2020, Delphi technique in health sciences: a map, Front Public Heal source

      Category 4.b (Number of Rounds) reports that two or three rounds were most common across the Delphi studies reviewed, so three rounds fits that observed pattern. It does not establish that two or three rounds were most common specifically in classical Delphi studies, which it distinguishes from modified Delphi studies. (LLM, conf=0.81)

      Experimental — accuracy not yet measured
    • cites [41] Spranger, 2022, Reporting guidelines for Delphi techniques in health sciences: a methodological review, Z Evid Fortbild Qual Gesundhwes source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In the first round, there were 62 contributions from experts which resulted in new questions for the next round.

    “there were also 62 contributions from the experts which resulted in the formulation of new questions for the next round.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingnone given

    The final algorithm was developed with all items for which a consensus of more than 70% was reached.

    “The final algorithm was developed with all the items for which a consensus of more than 70% was reached.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The algorithm in the form of a flow chart has a numerical code to follow the direction of each option and a colour code showing the classification of each item (anamnesis, examination, observation, referral, palpation and treatment).

    “The algorithm in the form of a flow chart (see Supplementary File) has a numerical code with which the direction of each option can be followed, and a colour code that shows the classification of each of the items (anamnesis, examination, observation, referral, palpation and treatment).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In all rounds, 7 participants from 5 countries participated.

    “In all the rounds 7 participant from 5 countries participated.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingnone given

    Items on which consensus was not reached were discarded from the algorithm.

    “The items on which consensus was not reached were discarded from the algorithm.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    All panel members were osteopathic clinicians and postgraduate teachers in the osteopathic temporomandibular joint field.

    “All the panel were osteopathic clinicians and postgraduate teachers in the osteopathic TMJ field.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The algorithm diagram starts with 4 main items: psychological aspects, exclusion criteria, physical aspects, and other issues, which are subdivided into other items followed according to findings during the patient visit.

    “The diagram starts with 4 main items: psychological aspects, exclusion criteria, physical aspects, and other issues, which are subdivided into other items that will be followed according to the findings found during the visit with the patient.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The consensus obtained in the first round was quite high and declined as the rounds progressed, largely because of new contributions made by each of the panellists.

    “The consensus obtained in the first round was quite high and declined as the rounds progressed, largely because of new contributions made by each of the panellists.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisereasoning

    No expert-consensus clinical guidelines or validated osteopathic approaches for the management of temporomandibular disorders with osteopathic manipulative therapy exist.

    “At present, there are still no clinical guidelines in the form of a flowchart that are agreed upon by experts for the management of TMDs with OMT.”
    • Also stated in: § Discussion · plain
      “However, as an independent discipline, no protocols or clinical guidelines for the OMT management of TMDs have been found.”
    • Also stated in: § Discussion · plain
      “Currently, there are no evidence-based clinical guidelines or validated osteopathic approaches with expert groups.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The literature search conducted for the first round was comprehensive enough to establish that no expert-consensus clinical guidelines or validated osteopathic approaches for TMD management with OMT exist.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Participants were kept anonymous during all rounds to ensure they could express themselves freely.

    “Participants were kept anonymous during all rounds to ensure that they could express themselves freely throughout the entire process.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Consensus was considered reached for responses with 70% or more agreement.

    “Consensus was considered to have been reached for those responses that were 70% or more in agreement.27”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [27] Diamond, 2014, Defining consensus: A systematic review recommends methodologic criteria for reporting of Delphi studies, J Clin Epidemiol source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    During the whole Delphi process, there were no withdrawals from the experts.

    “During the whole process there were no withdrawals from the experts.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Although a reasonable number of experts without dropouts was reached, participation was lower than anticipated.

    “Additionally, although we reached a reasonable number of experts without any dropouts, the participation was lower than anticipated.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The Consolidated Criteria for Reporting Qualitative Research (COREQ) were considered to report the study.

    “The Consolidated Criteria for Reporting Qualitative Research32 were also considered to report it.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32] Tong, 2007, Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups, Int J Qual Heal Care source

  • May combine two claims.

    Study design and conductown data

    The expert panel consisted of 7 osteopaths from different countries who met selection criteria: trained according to the European standard, postgraduate teachers specialized in the orofacial region, and/or having conducted research in orofacial pain or temporomandibular disorders.

    “The expert panel consisted of 7 osteopaths from different countries, who met the following selection criteria: be osteopaths trained according to the European standard,31 be postgraduate teachers specialized in the orofacial region in schools recognized by the registry of the country in which they are practicing, and/or have conducted research in the field of orofacial pain or DTMs.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [31] 2021

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    An insufficient number of clinical guidelines have been developed using the Delphi method, which is highly recommended for this purpose.

    “An insufficient number of clinical guidelines have been developed using the Delphi method, which is highly recommended for this purpose.26”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Banno, 2020, The majority of reporting guidelines are not developed with the Delphi method: a systematic review of reporting guidelines, J Clin Epidemiol source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    There is no universally accepted methodological guideline for applying the Delphi method in a more standardized manner.

    “Lastly, it is worth noting that there is no universally accepted methodological guideline for applying the Delphi method in a more standardized manner.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    During the final phase, all experts gave their approval to the algorithm result.

    “During the final phase, all experts gave their approval to the algorithm result.”
    Quote in the paperSubstantial claim
21 of 21

  • The paper relies on this without support.

    A panel of 7 osteopaths is sufficient to produce a valid expert consensus algorithm for the management of temporomandibular disorders with osteopathic manipulative therapy.

    “Additionally, although we reached a reasonable number of experts without any dropouts, the participation was lower than anticipated.”

  • The paper relies on this without support.

    The literature search conducted for the first round was comprehensive enough to establish that no expert-consensus clinical guidelines or validated osteopathic approaches for TMD management with OMT exist.

    “For the first round design, we conducted a search through existing literature on the diagnosis and management of TMDs, including all diagnostic types related to the osteopathic field, which was carried out in PubMed, CINAHL Plus, Scopus, Cochrane Library, and PEDro.”
2 of 2

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Third-round item count exceeds unresolved first-round items

    Minor

    The paper says the third round consisted of items that had not reached consensus in the first questionnaire. Only 23 first-round items lacked consensus (118 − 95), not the reported 36 third-round items.

    Reported 36 · recomputed 23

  • Total questions and consensus items are reversed

    Minor

    The Results section says 182 questions were asked and 258 reached consensus, but the abstract says 182 of 258 items reached consensus. The round totals also support 258 questions (118 + 104 + 36) and 182 consensus items (95 + 69 + 18).

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 4

  1. 2008, Guideline on acquired temporomandibular disorders in infants, children, and adolescents, Pediatr Dent, 30, 202
  2. Reguant-Álvarez, 2016, El mètode Delphi, REIRE Revista d’Innovació i Recerca en Educació, 9, 87
  3. Arias Capote, 2019, Utilidad de las guías, protocolos y algoritmos en la práctica clínica, Rev Cuba Med, 58
  4. Martínez, 2009, Árboles de decisión como herramienta en el diagnóstico médico, Rev Médica la Univ Veracruzana, 9, 19

Cited by

Sorted by citations

Authors
De-La-Iglesia, L., Bravo, C., Justribó-Manion, C., Montmany, A., Roman-Arias, T., Hue, I., Dugailly, P.-M., Colasanto, S., Van-Caille, P., & Rubí-Carnacea, F.
Affiliations
  • Universitat de Lleida (ES)
  • Universitat Abat Oliba CEU (ES)
  • Universitat Ramon Llull (ES)
  • Cooperativa de Ensino Superior Politécnico e Universitário (PT)
Corresponding author
Bravo, Cristina
ORCID
Venue
Journal of Chiropractic Medicine
Publisher
National University of Health Sciences
Published
2025
Volume
24
Issue
1-4
Pages
219-225
ISSN
1556-3707 (ISSN-L)
DOI
10.1016/j.jcm.2025.09.034
PMC
PMC12804032
OpenAlex
W4415321890
Cited by
1
References
35
Citations by year
2026: 1
FWCI
1.02
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Chiropractic Medicine (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • Repositori ObertUDL (University of Lleida) (publishedVersion, cc-by)
  • PubMed Central (submittedVersion, cc-by-nc-nd)
  • Repositori ObertUDL (University of Lleida) (submittedVersion, cc-by-nc-nd)
Topics
  • Health Sciences › Health Professions › Complementary and Manual Therapy › Temporomandibular Joint Disorders
  • Health Sciences › Medicine › Surgery › Facial Trauma and Fracture Management
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Cell Biology › Myofascial pain diagnosis and treatment
Keywords
temporomandibular disorders, osteopathic manipulative treatment, clinical decision algorithm, diagnosis and treatment, Delphi consensus, expert consensus, medical history, physical examination, palpation, referral

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-12.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-12.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review