General Assessment of the Patient with Temporomandibular Disorders

IntensityVisual analog scale (VAS) Validity is reliable (gold standard of pain assessment)Intensity - VAS Score of 1-3 =Mild painIntensity - VAS Score of 4-6 =Moderate painIntensity - VAS Score 7-10 =SeverePain quality description - Pain categoryMusculoskeletal Neurovascular NeuropathicPain quality description - Pain category MusculoskeletalDull, aching, pressure, depressing, tight, stiff, occasionally sharpPain quality description - Pain category NeurovascularThrobbing, stabbing, pounding, rhythmicPain quality description - Pain category NeuropathicShooting, bright, stimulating, burning, itchy, electric schock-like, cuttingFrequencyEpisodic / paryoxysmal ContinuousFrequency - Episodic / paroxysmalPain comes and goes "Intermittent"Frequency - ContinuousPain is always there Intensity can varyDurationSeconds Minutes Hours DaysDuration - SecondsMost commonly associated with trigeminal neuralgiaDuration - MinutesMost commonly associated with musculoskeletal disorders such as myofacial trigger pointsDuration - Hours/daysMost commonly associated with neurovascular pain (migraines/headaches)Aggravating factors - Musculoskeletal painRelated to biomechanical function (imitated by eating hard food, talking, yawning, etc)Aggravating factors - Pain of trigeminal neuralgiaSpontaneous or triggered by light touchAlleviating factorsPain medications Avoidance of functions Heat/coldWhat is temporomandibular disorders?A collective term embracing a number of clinical problems that involve the muscles of mastication, the temporomandibular joint, or bothTemporomandibular joint includes:Bones (condyle and glenoid fossa) Disc LigamentsTemporomandibular needs what to function?Assistance of muscles of masticationMuscles of mastication include:Masseter Medial/lateral pterygoid TemporalisTMD patient evaluationPalpate the muscles of mastication and cervical muscles Palpate the TMJ intrameatally and/or preauricularly Measure range of motion and its association with pain Auscultate and palpate for joint noises in all movements Guide mandibular movement, noting pain and joint noiseMuscle evaluationShould be palpated bilaterally Two techniquesMuscle evaluation - Two techniquesFlat PincerMuscle evaluation - FlatPress muscle against bone such as masseter, temporalis, and sub occipital musclesMuscle evaluation - PincerRecommended when belly of muscle can be grasped between thumb and forefingers (SCM and upper trapezius)What muscles should be palpated bilaterally?Temporalis Occipitalis Splenius capitis Sternocleidomastoid Deep / superficial masseter Medial pterygoid Lateral pterygoidWhere should the provider stand when palpating muscles?In from of the patient to detect facial responses during examinationMuscle evaluation - Application of pressure6-10 kg (13.2-22 pounds) of pressure for 10 secondsHow to know if you are using the correct amount of pressure?The tissues will blanchGrading tenderness on palpation0 = no pain 1 = mild pain 2 = moderate pain (palpebral response) 3 = severe pain (avoidance response)Myofascial painFirm hyper-sensitive tender band of muscle tissue Dysfunction Pain reference/trigger pointClinical features of myofascial trigger pointsPresence of taut band (hard knot)FlipTrigger point = SCM Pain felt in sternum, head, face, etc.Identify the trigger point / where the pain is felt?Flip backPalpation of temporalisUse 2 fingers to apply pressure to 3 fibers (anterior, middle, posterior)Palpation of trapeziusTrigger points approximately midway between origin and insertion of musclePalpation of sternocleidomastoidBellies of both muscles should be examined simultaneously using pincher palpation Flat palpation for sternal and clavicular headsPalpation of SCM - If trigger point detectedEach muscle should be examined separatelyPalpation of masseterFlat palpation recommended for superficial and deepPalpation of masseter - SuperficialOrigin palpated along zygomatic arch Belly examined by pressing muscle against mid-ascending ramus of mandible Insertion palpated against lower portion of ascending ramus of mandiblePalpation of masseter - DeepPalpated by pressing against ascending ramus of mandible just in front of TMJPalpation of medial ptergyoid - IntraoralPress against medial aspect of ascending ramus May illicit gag reflexPalpation of medial pterygoid - ExtraoralPalpating insertion of muscle on medial surface of angle of mandibleMandibular sling =Masseter + medial pterygoidTesting of lateral pterygoidUse functional tests of provocation against resistance Protrusive / OpeningTesting of lateral pterygoid - Protrusive movement against resistanceTests inferior bellyClosing against resistance tests...Mandibular elevators (Temporalis, masseter, medial pterygoid)Jump signSpontaneous reaction to palpation that can manifest as a verbal response or withdrawal Needs to be distinguished from local twitch responseTwitch responseRapid contraction of muscle elicited by palpation of band at location of trigger pointTMJ examination consists of 3 parts:Range of motion Joint sounds TendernessMandibular range of motion - Determined by measuring:Maximum opening R/L lateral excursions Protrusive excursionMandibular range of motion - Normal mandibular opening is estimated ranging from...40-55 mm< 40 mm mandibular openingLimited openingMandibular range of motion - GenderLower in women than in menMandibular range of motion - AgeDecreases with increasing ageActive range of motion (AROM)Full unassisted mouth openingPassive range of motion (PROM)Assisted mouth openingPROM helpful in _______ patientHypermobileExcursive movements8-12 mm R/L lateral movements Reference mark made on incisors Movements made without any posterior tooth contact and with slight opening between incisorsMandibular gaitManner or pattern of movement Quality and symmetry of jaw movementsDeviationMovement of mandibular midline to one side on early opening which returns to center position at end of opening (slowing of condylar movement in one join)Deviation - Very common characteristic in:Anterior disc displacement with reductionDeflectionWhen mandible continuously moves to one side on opening and doesn't return to midlineDeflection - Prominent clinical sign ofIntracapsular problem such as anterior disc displacement with out reduction May also be caused by spasm of ipsilateral masseter or contralateral inferior lateral pterygoid musclePalpation of TMJ wallsLateral and posterior Should be palpated simultaneously using digital pressurePalpation of TMJ walls - Lateral walls10-20 mm in front of external auditory meatusPalpation of TMJ walls - Lateral walls Tenderness =Capsulitis or synovitis of TMJPalpation of TMJ walls - Posterior wallsSlide index fingers into depression created behind condyles as patient opensPalpation of TMJ walls - Posterior walls Tenderness =Retrodisc guidance or inflammation of retro-discal spaceAuscultation - Joint soundsIntracapsular pathology Functional adaptation Are common in general populationAuscultation - Joint sounds Intracapsular pathologyInternal derangements Degenerative processes Defects of the bony architecture Defects of the articulating surfacesThere is a conflict as to whether auscultation is ___________ in detection of joint soundsReliable and repeatableBest way to auscultate TMJWith stethoscope placed over lateral wallJoint soundsClick Crepitation (crepitus)Joint sounds - ClickSingle noise of short duration Indicates a displaced articular disc that reduces into the correct anatomical position upon openinJoint sounds - Click - Most associated withDisplacement with reduction and will represent the passage of the condyle under the posterior border of the discJoint sounds - Crepitation (crepitus)Noise of long duration Associated with a degenerative changesLoad testApplies selective loading on TMJ Permits condyles to move superiorlyLoad test interpretation If pain (discomfort) is referred on the same side (ipsilateral) where the test is performedMuscular painLoad test interpretation If pain (discomfort) is referred on the opposite side (contralateral) where the test is performedJoint pain