Initial Evaluation of TMJ Patient

Question 1

steps to evaluating TMJ patient

Answer 1

1. hx
2. clinical exam
3. studies (imaging)
4. assessment
5. plan (with discussion)

Question 2

what is the most important part of workup of TMJ patient?

Answer 2

hx

Question 3

critical elements of hx of TMJ patient

Answer 3

1. pain hx
2. previous tx and outcome
3. joint sounds
4. functional limitations

Question 4

LIQORAAA of pain hx

Answer 4

L - location
I - intensity
Q - quality of symptom
O - onset of symptom and precipitating factors
R - radiation of symptom
A - associated symptoms (joint sounds, other neurological oddities)
A - alleviating factors (avoid jaw fxn, etc.)
A - aggravating factors (chew, sing, talk a long time)

Question 5

previous tx of TMJ

Answer 5

1. splint therapy
2. physical therapy
3. medications (NSAIDs, muscle relaxers)

Question 6

what should be asked of TMJ patient who had previous occlusal splint therapy?

Answer 6

1. type
2. start and duration of tx
3. wear
4. outcome

Question 7

what should you especially note of TMJ patient who had previous occlusal splint therapy?

Answer 7

change in symptoms on awakening, change in distribution of pain

Question 8

what should be asked of TMJ patient who had previous physical therapy?

Answer 8

1. duration, number/frequency of visits
2. modalities used
3. outcome
4. home care instructions

Question 9

what should be asked of TMJ patient who had previously taken medication to tx issue?

Answer 9

1. which one(s)
2. duration of therapy
3. scheduled vs prn
4. result

Question 10

what should you also note of TMJ patient who had previously taken medication?

Answer 10

other concurrent meds that may be helping (or worsening) the symptoms

Question 11

T/F: it is important to distinguish between pop, click, or snap sound when tx’ing TMJ patient

Answer 11

false, no relevant distinction, just sound different

Question 12

what should be documented with crepitus/grinding/”bone-on-bone”?

Answer 12

1. onset

2. subsequent change

Question 13

when examining functional limitations, what should you be able to distinguish?

Answer 13

between general stiffness (muscular) from mechanical obstruction (internal derangement, arthropathy)

Question 14

stiffness

Answer 14

can stretch more (with pain) vs moves okay then hits a brick wall

Question 15

catching

Answer 15

opens easily part way but gets caught at 1-2 finger-widths of opening, then opens the rest of the way

Question 16

closed lock

Answer 16

like a catch, but stays that way for minutes, hours, days, etc.

Question 17

extremely limited, unchanging ROM may indicate what?

Answer 17

ankylosis

Question 18

functional limitations

Answer 18

1. limited/impaired movement
2. limited diet
3. malocclusion
4. other neurological problems

Question 19

T/F: to check for malocclusion, you should try to retrude the chin

Answer 19

false, don’t

use tongue trick to establish CR position

Question 20

TMJ patients have a high incidence of what?

Answer 20

1. depression/anxiety

2. fibromyalgia

Question 21

inspection of TMJ patient includes what?

Answer 21

1. facial asymmetry
2. swelling
3. asymmetric facial movements
4. masticatory muscle hyperplasia, hyperactivity

Question 22

palpation of moderate pressure over masticatory muscles

Answer 22

10 lbs

Question 23

palpation of light pressure over lateral capsules

Answer 23

5 lbs

Question 24

T/F: pterygoid muscles are directly palpable

Answer 24

false, not directly

Question 25

preauricular tenderness may be what type of finding?

Answer 25

either joint or muscle finding

Question 26

what should be considered in highly sensitive TMJ patients?

Answer 26

neuropathic pain (e.g. tactile allodynia, hyperalgesia)

Question 27

muscle palpation should be worked from top down starting at what?

Answer 27

temporalis crest

Question 28

what should you look for with muscle palpation?

Answer 28

1. tenderness 2. increased tone 3. taught bands 4. trigger points

Question 29

what should be noted when you press upward from pterygomandibular sling during muscle palpation?

Answer 29

radiation or distant site of pain

Question 30

what should be palpated during joint palpation?

Answer 30

lateral capsule area

Question 31

how much pressure should there be with endaural palpation?

Answer 31

with light anterior pressure

Question 32

T/F: pressure on posterior border of mandible should always be done during joint palpation

Answer 32

false, always painful so avoid it

Question 33

what is involved in clinical exam?

Answer 33

1. inspection 2. muscle palpation 3. joint palpation 4. functional examination

Question 34

functional examination

Answer 34

open wide as possible without pain (or without worsening pain), measure

Question 35

T/F: overbite amount should not be included in measurements when performing functional exam

Answer 35

false, always include

Question 36

what should be noted during functional exam?

Answer 36

1. location and severity of pain separately for each movement 2. abnormal movement of jaw

Question 37

T/F: during the functional exam, you should gently keep fingers over lateral capsules during movements

Answer 37

true

Question 38

palpate posterior maxillary vestibule... if lateral/posterior

Answer 38

masseter origin

Question 39

palpate posterior maxillary vestibule... if posterior on ascending ramus

Answer 39

temporalis insertion

Question 40

how to check indirect load to lateral pterygoids

Answer 40

press chin area posteriorly and/or superiorly against resistance with mouth half open (half of patient's best opening)

Question 41

how to know if there is indirect load to lateral pterygoids

Answer 41

presence of pain in preauricular area (TMJs) or deep under cheekbone (lateral pterygoid)

Question 42

functional load

Answer 42

bite tongue blade between most posterior teeth bilaterally and incisors

Question 43

what should be noted during functional load exam?

Answer 43

location and severity of pain to determine muscle vs joint area

Question 44

intraoral examination

Answer 44

1. measure overbite, overjet 2. angle classification 3. absence of posterior stops

Question 45

guarding

Answer 45

excessive limitation of ROM

Question 46

tricks to detect guarding

Answer 46

1. observe during interview, note interincisal ROM | 2. look for tonsillar hypertrophy with tongue blade

Question 47

a few minutes after the physical exam, why should you ask the patient if her jaw hurts now, record positive response and pain detains?

Answer 47

to look for induced pain

Question 48

panoramic film screens for what?

Answer 48

gross joint pathology and other potential problems

Question 49

T/F: on a pano, it'll demonstrate joint space reliably

Answer 49

false, NOT

Question 50

what type of radiograph is best for suspected bony abnormality (i.e. ankylosis, severe arthritis)?

Answer 50

CT

Question 51

what type of radiograph is best for internal derangement and effusion?

Answer 51

MR

Question 52

T/F: most radiographic findings have weak or no correlation with clinical findings or symptoms

Answer 52

true

Question 53

what is frequently found in asymptomatic control populations?

Answer 53

ADD (12-45%)

Question 54

condylar changes may be what?

Answer 54

arthritic or adaptive

Question 55

T/F: systematic review find little if any literature support for a link between findings and clinical relevance

Answer 55

true

Question 56

effusions are strongly associated with what?

Answer 56

ADD (+/- reduction) and pain