the face pain exam Flashcards
what mm can we palpate for the exam
massetter and temporalis (ant, middle and posterior bellies)
indicate which side caused pain too
joint palpation and auscultation
palapte the joint and use sethoscope to listen for creptius or other noises present
TMJ ROM measures
incisal overlap
vertical range
R/L excursive movements
always note where pain occurs in any of these moves
what if one side has less excursive movement what should be suspected?
suspect disc displacement (anteromedial) on the opposite side
The Pain History is?
components of this?
The Pain History is Subjective
1. CC (Patient’s Chief PAIN Complaint)
2. HPI (History of Present Illness)
3. PMHx (Past Medical History) y)
4. psychosocial hx
5. ROS (Review of Medical Systems)
- CC (Patient’s Chief PAIN Complaint)
- CC (Patient’s Chief PAIN Complaint) – why is patient seeking
treatment? IN THE PATIENT’S OWN WORDS
- HPI (History of Present Illness)
- HPI (History of Present Illness) Facial Pain (location, chronicity,
quality, frequency, duration, triggers, modifying factors),
associated trauma, and Habits- NOT MEDICAL HISTORY
- PMHx (Past Medical History)
- PMHx (Past Medical History) that is pertinent to PAIN CONDITION –
surgical history, medications
- Psych/Soc (Psychosocial History)
- Psych/Soc (Psychosocial History)- anxiety, depression
- ROS (Review of Medical Systems)
- ROS (Review of Medical Systems)- includes an assessment of
appetite, sleep patterns, activity levels, energy levels, headache
history, ear, eye, sinus problems, jaw dysfunction including
noises, locking history, cervical dysfunction and pain, back pain,
lung, heart, GI, GU, Liver, Kidney problems, neurological and
other musculoskeletal problems.
Is there arthritis, fibromyalgia, migraines that may contribute or
cause the pai
Screening Questions for TMD
Ask your patient if she/he experiences:
1. Difficulty &/or pain with?
2. Jaw locking, sticking or the jaw going out of joint?
3. Pain with?
4. noises?
5. Stiffness, tightness or tiredness?
6. Pain in or near?
7. Frequent?
8. Recent changes in?
9. Recent injury to?
- Difficulty &/or pain with mouth opening
- Jaw locking, sticking or the jaw going out of joint
- Pain with chewing, talking or using jaw
- Jaw joint noises
- Stiffness, tightness or tiredness in the jaw
- Pain in or near the ears, temples, or cheeks
- Frequent headaches, neck aches or toothaches
- Recent changes in your bite
- Recent injury to the jaw, neck or head
- Past treatment for facial pain or a jaw joint problem
Comprehensive History for Orofacial Pain
If the patient responded positively to any of the screening
questions, it may require?
Your decision as a dentist to complete a TMD comprehensive
exam should be based on?
If the patient responded positively to any of the screening
questions, it may require a comprehensive history and clinical
TMD examination
Your decision as a dentist to complete a TMD comprehensive
exam should be based on the patient’s level of concern and
clinically significant findings from your oral exam and
extraoral exam
what factors should be assessed for a consult
pain quality, pain severity, duration, frequency, aggrevated by, 24hr variation, joint noises, locking, past tx, current tx
HPI (History of Present Illness): pain questions
Date of Onset of Pain
Pain Problem (i.e. Facial pain, toothache)
Pain Location (ask pt to point, i.e. Left TMJ)
Pain Quality
Pain Severity
HPI (History of Present
Illness):
Duration of?
Frequency of?
Variability:
Habits-
Aggravating and ameliorating factors?
24 hour variation?
Duration of pain
Frequency of pain
Variability: continuous or intermittent (ask pt if pain is there every minute all day long or does it come and go); is pain spontaneous or triggered
Habits- clenching, biting on lips/cheeks, pens, fingernails, chewing gum
Aggravating and ameliorating factors
24 hour variation (i.e. worse on awakening
or during day
how can we see clenching if pt doesnt know
likely to have a scalloped tongue
other causes of scalloped tongue
hypothyroidism (due to macroglossia) and obstrucuve sleep apnea
what should we do with night guard pt has
examine, if cracked its useless
when is a TMD consult needed:
mouth opening?
noises?
Change in?
Masticatory Muscle?
TMJ ?
Abnormal pain in face, teeth or headache esp. following?
Panorex shows?
Needed if patient has:
Limited mouth opening < 35mm
Clicking, popping or grinding noises in TMJ with PAIN
Change in occlusion
Masticatory Muscle pain
TMJ pain or locking
Abnormal pain in face, teeth or headache esp. following extraction, RCT, surgery or implant
Panorex shows degenerative changes on TMJ, Fracture or other abnormality
exam set up
shimstock for occ
load joint unilaterally with depressors
ruler to measure ROM
needle for noxious stim
click vs crepitus
click is displaced crepitus is degen
ROM components for extraoral exam
comfy opening 9no pain0
max unassisted open (pain present)
max assisted open (dentist opens further)
protrusion
R/L lat. extrusion
+/- midline deviation to excursions
subtract from side going towards and add to opposite side
normal opening
40-60mm
normal r/l excursion
9-12mm
Range of Motion
Note pain location with?
With passive stretch, note?
Feel the TMJ’s on opening. Do they?
Note pain location with all movements
With passive stretch, note “end feel” – is it soft or hard?
Feel the TMJ’s on opening. Do they both translate?
what doe this patten indicate
Disc displacement with reduction and corrected deviation
shift to side of disc interference but returns after disc reduction
what does thi pattern indicate
disc displacement with no reduction, deflection
midline is continulally deflected to affected side with limited opening
Joint Sounds (Auscultation)
- Listen with a stethoscope while the patient opens maximally &
closes , protrudes, and moves laterally - Listen for clicking, popping, or crepitus (grinding) and note when it occurs during mouth opening & closing
Muscle Palpation Exam
1. Explain to patient that you will be? scale?
NOTE: Leaving it blank means?
2. Tell the patient that they should tell you if the pain?
Muscle Palpation Exam
1. Explain to patient that you will be applying pressure on the
muscle and ask them to rate the pain as Mild, Moderate or Severe
or numerically as 0, 1, 2, 3 respectively
Please RECORD pain rating as:
“0”- No pain
“1”- Mild pain
“2”- Moderate pain
“3”- Severe pain
NOTE: Leaving it blank means that you did NOT do the
examination.
2. Tell the patient that they should tell you if the pain spreads
out and point to the area where the pain is spreading to (this is
referred pain known as myofascial pain)
trigger points of mm exam
Trigger Points (TPs) in any voluntary muscle which cause
referred pain and referred tenderness and may be
active or latent. (3
Extraoral Muscle Palpation
Exam mm’s
Temporalis
Masseter
Temporalis Muscle palpation
Temporalis Muscle: Palpate
Anterior, middle, posterior with
mouth open
Superficial Masseter Muscle palpation
Superficial Masseter Muscle:
Palpate Superior, mid-, inferior &
deep masseter with mouth open
Trigger Point Referral Patterns of the masseter (superficial and deep)
Trigger Point Referral Patterns of the temporalis
Intraoral Muscle Exam
Medial pterygoid
Lateral pterygoid area/tendon of temporalis- ask the
patient to move his/her jaw to the same side you are
palpating
digastric pain referal patterns
medial pterygoid referal patterns
intraorla palpation could trigger?
electric pain, allodynia, burning pain
Evidence of Parafunction
Defined Linea Alba from Teeth Clenching or scalloped tongue
habits of interest to pain
Clenching/bruxism
Biting on nails, cheeks, lips, tongue, pens
Protrusion
Gum chewing
Jaw tension
Unilateral chewing
attrition
Radiographic Exam
ideal one? shows?
Does NOT show?
May request?
May request an MRI to evaluate?
Panorex- can evaluate maxilla, mandible, teeth and TMJ on
one film.
Does NOT show Lateral view of TMJ
Does NOT show open and closed mouth views so translation, joint spacing cannot be evaluated
May request a lateral view with a CBCT or CT
May request an MRI to evaluate disc displacement or other pathology
How long should you palpate a masticatory muscle to determine if there is pain?
1-2 seconds
When you perform the passive stretch during measuring mouth opening and there is no increase in motion with a hard end feel and opening <35mm, this commonly suggests restriction within which anatomical structure?
TMJ
