The Detection and Management of Temporomandibular Disorders in Primary Dental Care
Course Number: 395
TMD Clinical Examination
Patients who have positive responses to a brief screening questionnaire will potentially benefit from a clinical examination. A brief clinical examination,9 with the aid of an assistant, should only take a few minutes to complete. The examination and specifications below have been adapted from reliability and validity studies of TMD examinations and diagnostic criteria8 and provide the key information to identify the patient’s clinical diagnoses. This examination collects information about the patient’s pain history, opening and excursive ranges of motion, joint sounds and pain on palpation of the masticatory muscles and TMJs.
Table 3. TMD Clinical Examination Form.
Brief Specifications for Conducting the Clinical Examination
Mandibular openings: use a millimeter (endodontic) ruler to measure from the incisal edge of the maxillary to mandibular central incisors, and adjust (add for incisal vertical overlap).
Unassisted opening without pain: ask the patient to open as wide as possible without bringing on any (additional) pain.
Unassisted opening with pain: ask the patient to open as wide as possible in spite of causing pain.
Maximum assisted opening: ask the patient to open as wide as possible and apply a moderate amount of pressure to assist the patient to open wider.
Muscle Palpations: palpate the central portion of the temporalis and masseter muscles. Ask the patient to let you know when tenderness is felt; start with light pressure and increase up to 2-3 pounds. Stop as soon as tenderness is felt or 2-3 pounds is reached. If unable to reproduce the patient’s pain, ask the patient to feel for and point to its location, then palpate this region of the muscle.
TMJ Palpations: ask the patient to open about 1-1.5 inches and palpate the lateral pole up to 1 pound, in a similar manner as the muscles were palpated. Then palpate in a circle around the lateral pole with up to 2-3 pounds in a similar manner as the muscle palpations.
TMJ sounds: place a finger over the TMJ as the patient opens, closes, and moves laterally. It can take up to three movements in each direction before a joint sound may be detected. To best detect joint sounds the patient should open fully, completely close and move in each side as far as possible, even if pain is present.
The TMD evaluation is primarily based upon history and clinical evaluation, TMJ imaging is only performed if there is a reasonable expectation that the obtained additional information will influence the patient’s treatment.4 In some cases definitive imaging is needed. To determine the actual position of the articular disc, an MRI provides the best diagnostic information. The status of osseous structures such as the condyle, are best viewed with Cone Beam Computed Tomography (CBCT) imaging. A review and receiving a report by a radiologist, such as an oral and maxillofacial radiologist, is recommended.
There are other potential assessments that can be used, however, the choice of adjunctive diagnostic procedures should be based upon published, peer-reviewed data showing diagnostic efficacy and safety.10 Additionally, they should only be performed if there is a reasonable expectation that the obtained additional information will influence the patient’s treatment.
Occasionally, but rarely, aggressive local pathology can present with signs and symptoms similar to TMD and all patients who are being evaluated for TMD should receive a careful and comprehensive head and neck assessment.