Delchano TMD Screening – Exam Prep

TMD – is used to describe a whole group of conditions which present as pain in the face of jaw area, limited mouth
opening, closed or open lock of the TMJ, abnormal occlusal wear, clicking or popping sounds in the jaw joints and other
complaints.
Is a collection of medical and dental conditions affecting the TMJ and muscles of mastication, as well as contiguous
tissue components resulting in pain and dysfunction. The pain and dysfunction is directly related and aggravated by jaw
use.

Primary clinical features of TMD

 Pre-auricular pain
 Painful jaw use
 Tenderness of TMJ and masticatory muscles to palpation
 Restriction of jaw movement
 Interference with jaw movement
 Headache
Other clinical features
 TMJ sounds
 Intermittent fascial swelling
 Ear symptoms (discomfort)
 Occlusal change/discomfort
 Mandibular dyskinesia

Screening and Examination

This should be performed for every patient, in order to assess the relative risk for proposed dental treatment. It should
involve a questionnaire and then an examination.
The decision to treat is influenced by
- Pain intensity
- Symptom progression
- Associated disability
- Presence/absence of TMD

Screening Questionnaire
1. Do you have difficulty/pain when opening your mouth?
2. Does your jaw ever get stuck/locked?
3. Do you have any pain/difficulty when chewing/talking/using jaw?
4. Are you aware of any joint noises?
5. Do you have pain in the ears/temples/cheeks?
6. Does your bite feel uncomfortable or unusual?
7. Do you have frequent headaches?
8. Have you had a recent injury to the head/neck/jaw?
9. Have you ever had treatment for jaw joint problems?
*** Questions should be directed at onset, frequency, duration, intensity, progression, and dysfunction

The patient should fill this out before they see you ie in the waiting room. This questionnaire should determine whether
or not the patient has TMD. If they answer yes to the first three questions then it is quite likely that they have TMD. If
they answer yes to the other questions then it is a cause for further investigation.

Screening Examination
If the patient cannot open then you have to do the opening for them (passive stretch). You should feel whether it is a
hard or soft end feel. A soft end feel means the problem originates from muscle pain and a hard end feels indicates that
it is capsular.
TMJ Range of Motion
Note whether it is smooth or rough.
Amount of opening. If limited opening (indicative of joint hypomobility) is not treated then it can result in increased joint
lubrication is compromised. Joint restriction can be an early indication of severe pathology. It is important to note that
ROM in the TMJ normally decreases slightly with age. TMJ patients often have excessive opening because the joint
capsule is stretched (hypermobility). In extreme cases the joint becomes unstable and may dislocate. The masticatory
muscles do not function effectively if the opening is too wide. Normal anterior opening is approximately 40mm but
varies from patient to patient and measurements can be inaccurate due to overjet and overbite.
Direction of opening. The maxillary midline is used as a stable reference point against which mandibular movement is
assessed. The examiner determines wat what point in the cycle the opening deviation occurred, this information is more
important than the amount of deviation because it can distinguish between the different conditions. <Fig 5.11> A
straight pathway is normal, deviations to right or left but then to midline indicate bilateral disc dysfunction, deviation to
one side indicates a unilateral restricted joint (anteriorly displaced) to the side of the deviation, and you can also have
unrestricted deviation which often results from a muscular habit or imbalance.
Protrusive and laterotrusive. Restriction or deviation may indicate a dysfunction. Pain or restriction may indicate one of
the following conditions: joint inflammation, muscle dysfunction, coronoid process impingement, or an anteriorly
displaced disc (which is the most common and can be suspected if there is an appreciable difference in lateral excursions
between the two sides)
Resistance Tests (Static Pain)
If a pathologic conditions exists in the muscle, application of maximal resistance will result in pain or other symptoms.
The mouth must be partially opened (about 1cm) as this ensures that the inert structures of the joint are relaxed when
the joint is in mid range. If pain is produced then the test should be stopped. The following muscles are tested resistively:
opening (lateral pterygoid), closing (masseter, temporalis and medial pterygoid), lateral excursion (medial and lateral
pterygoid), protrusive (medial and lateral pterygoid).
Loading Tests (Joint Detraction)
This tests the jaw closing muscles (masseter, tempolaris and medial pterygoid). Clench on the bite stick. If there is pain
on the same side then it is a muscle problem. If it is on the contralateral side then it is the TMJ problem on that side. Can
also test under function ie get the patient to chew gum whilst palpating the TMJ at the same time.
Injection
LA into the muscle, joint etc. When injecting the masseter, don’t use one with vasoconstrictor. Xylocaine has been
shown to be myotoxic so procaine is the best one to use.
Joint Sounds
Clicking is more in the younger population. Crepitus is found in the older population and has a sandpaper sort of feel to it
(often accompanied by grinding noises) and if present, is felt during the latter stages of opening. Crepitus indicates a
roughening of the surfaces of the condyle and articular eminence and possible destruction or anterior displacement of
the intra-articular disc. The possibility of osteoarthritis should be investigated. A combination is possible. Ask the patient
what they noticed.

Imaging
Plain films
OPG’s, reverse Towne’s (to see the neck of the condyle), lateral oblique, transmaxillary, transorbital, submental vertex,
transcranial. These are used for the screening procedure in order to screen for gross degenerative changes. Can also be
used to evaluate condylar translation and any pathological fracture.
CT/Tomography
Can be used for assessment of osseous changes, osteo-arthritic changes, lesions, narrowing of joint space which is
suggestive of non reducing disc displacement. Can also be used for bony abnormalities, neoplastic lesions,
developmental anomalies, trauma and pathology of the sinus.
Arthrography
This is highly invasive, uncomfortable and has high dose of radiation. A radio-opaque contrast medium is injected into
the inferior and/or superior joint space. This determines the position of the articular disc relative to the condyle. It
reveals the functional dynamics of the disc and condyle. It is the best medium to use for diagnosis of disc perforation.
MRI
Is the gold standard. It is painless and involves no radiation. It detects soft tissue pathologies in the head and neck. It is
very useful for diagnosis of TMJ pathologies such as internal derangement.
Radionuclide Imaging
Is used to detect high areas of osteoblastic activity (ie growth, neoplasia or inflammation) due to reactive bone
formation. It is used in suspicion of malignancy.

Clinical/Laboratory Tests
Can use intra-articular biopsy for diagnosis of neoplasia found in bone, cartilage and synovium.
Blood tests/urinalysis can be used in assisting with diagnosis of systemic disease.
Synovial fluid analysis (arthrocentesis) is tapping of TMJ then extraction of synovial fluid; biochemical markers for
degradation.
Study casts can be taken in order to evaluate bruxism over time, give a baseline record of tooth and jaw relationships.
The accuracy of mounting is affected by pain so control the pain first!
Electrodiagnostic tests
Jaw tracking devices
EMG: to check reflex activity, neural conduction
Thermography
Sonography
Vibration analysis