Treating TMJ in the Orthodontic Office - Diagnosis

By Randall C. Moles, D.D.S., M.S.
Racine, Wisconsin

The facial patterns that we deal with on a daily basis in our orthodontic practices have potential effects on the TM joints and surrounding musculature. The process of treating these patients begins with the diagnosis, which is the key to developing a successful treatment strategy. It will make or break you. If the diagnosis is accurate, treatment is most often successful and stable. If it is hazy or inaccurate, treatment time can be, at best, prolonged and, at worst, a failure.

The diagnostic process should begin when the patient first calls the office (Figure 1). Besides the usual clerical information, this is an ideal time to begin gathering the data that will assist the development of a diagnosis. The patient can be briefly asked about any previous treatments undergone for the problem, who provided the treatment and the degree of success that was obtained. It is very important that the patient be instructed to bring along any related medical records that they may have, along with any splints that they were given. From this, you can determine what does not work for this patient. The attitude of the patient toward treatment should also be noted, which will later aid in estimating a prognosis, treatment time and fee. Some patients are extremely talkative, which should be noted, since appointment times will need to be adjusted to accommodate them.

Scheduling TMJ Patients

While I am discussing the prospect of adjusting appointment times, it would be appropriate to discuss the scheduling of TMJ patients in general. One of the biggest mistakes many orthodontic practices make is to schedule TMJ patients the same way their orthodontic patients are scheduled. This is a serious error! The typical TMJ patient is in pain, and although it may be chronic pain of long standing, when they call your office they want to be seen quickly. Forcing these patients to wait many weeks for an examination, as we often do in orthodontic practices, creates a negative beginning to the patient experience, besides being just plain inconsiderate.

It is easy to set up your schedule to allow for a set number of TMD new-patient appointments each month. This can be determined from the average number of new TMD patients seen in the previous three months. If you see an average of 10 TMD patients a month, you should hold open between two and three TMJ slots each week. If a particular slot is not filled, it can be released for general scheduling three or four days prior to the reserved date. This assures that appointment times will be available for patients in pain.

Routine appointments for TMJ patients must also be handled differently from orthodontic patient appointments. Since these patients must be seen on a weekly or biweekly basis, major difficulties are created in the orthodontic office where patients are seen on a four- to six-week rotation. This can be remedied by always scheduling three appointments in advance. For example, a patient who is in the office today for a splint adjustment would have two more appointments previously scheduled and would receive another appointment one or two weeks after the last. This brings the scheduling of that patient’s appointment out far enough to allow for easier scheduling. Of course, as with orthodontics, time must be allowed in the schedule for emergency visits.

Interview and Examination

Upon arriving at the office, new TMJ patients are greeted warmly and asked if they brought the health history and pain chart that was mailed to them after their initial call to the office. The greeting staff member observes and notes any poor posture or unusual gait. After a brief tour of the office, a staff member interviews the patient in a private consultation room. The patient’s chief complaint and when their problems first began are noted. Previous evaluations and treatments by physicians, dentists and other health professionals are discussed in detail along with any relief that was obtained. This can give you an idea of what won’t work. Be on the lookout, however, for treatments that were incomplete. It is not uncommon to find a patient who has had splint therapy and was instructed to wear the splint only at night or who had splint therapy without any physical therapy. They may have been left with a very poor occlusion. It may only be necessary to provide a more complete and comprehensive treatment to resolve the problem.

These patients often suffer from more than one type of headache and each should be documented relative to the type, location, frequency and duration of the pain. For example, a patient may complain of daily "stress" headaches located in the back of the head - a mild, dull ache that occurs in the afternoon, usually on work days. The patient may also suffer from "sinus" headaches which occur once or twice a week - strong aching located around the eyes. Last of all, they may suffer from "migraines" that occur every few months, affect their entire head and are so severe that they are forced to miss work. All of these headaches may be a continuation of the same problem, possibly TMJ. This can be confirmed in the examination.

The type of headache can be misleading, since many of these patients have previously been misdiagnosed. What was diagnosed as migraine is often referred pain from trigger points in the masseters. What was diagnosed as sinus headaches is often referred pain from trigger points in the lateral pterygoid muscles. However, the patient’s description of the type of headache is useful since it defines the new patient’s problem and will be useful in evaluating future progress in their own terms.
The location of the pain is a critical factor in the diagnostic evaluation. Interviewing the patient as to the exact location of the pain is extremely important, for it can be correlated with the exam findings, especially trigger points. For example, if a patient’s pain is located directly above the eyes, you would look for trigger points in the sternocleidomastoid. If the pain is located directly below the eyes in the area of the maxillary sinuses, you would look for trigger points in the lateral pterygoid muscles. Trigger points in the sternocleidomastoid muscles respond very well to physical therapy while trigger points in the lateral pterygoid respond to splint therapy. In this way, the interview, examination and treatment are coordinated.
The frequency of the pain includes not only how often but also when it occurs. Both these factors are very important, for they can give you an idea of possible causative factors. For example, headaches that are present upon waking point to possible bruxing and occlusal problems. Headaches occurring later in the morning can be caused by low blood sugar if breakfast has not been eaten or by irritation of inflamed joints and muscles from speaking and chewing. Headaches occurring in the afternoon can be related to eye strain, irritation of already inflamed joints and muscles, or neck strain. Later in the day, neck strain often becomes a more significant factor. When you examine the patient, you can then look for confirmation of these possible causes.

The duration of the pain is often an indication of the severity of the problem and its resistance to treatment. You need to be especially concerned with pain of recent onset (a few months or less). Recent pain increases the possibility of a more serious medical problem. Therefore, be sure of your diagnosis or refer for medical evaluation. Long-standing pain reduces the chances that a life-threatening problem exists, although it does indicate that the treatment may take longer.
After you have determined the nature of the pain, you need to ask the most important diagnostic question, "Is there anything that makes the pain better or worse?" The answer will often reveal the cause of the problem and its treatment. If the patient indicates that the pain is aggravated by chewing, there is a high probability that it is a joint or muscle problem and will respond positively to a splint and physical therapy. Often the patient will say that the pain is relieved by moist heat, which indicates a muscle problem that would most likely respond well to heat and physical therapy. If they tell you that regular pain relievers don’t help, it is a sign that muscle pain is involved, since muscle pain is often resistant to pain medications. If they say that the pain increases while they are at work, you will need to question them about work habits which might create strain in the paracervical muscles. These neck problems tend to respond favorably to splint therapy because the splint will create a more upright head posture while relaxing the anterior cervical muscles. Many TMJ patients are under stress. Often, the stress comes from the pain itself and its negative effects on the patient’s life. It is always important to ask
questions about the level of stress the patient is experiencing. You can even give one of the various tests used to determine the stress level and even the source. If the patient indicates that they are under a lot of stress, referral for "stress counseling" may be appropriate. Also, don’t forget to ask the patient about how they are sleeping. A history of waking up at night and being tired in the morning may point to fibromyalgia, which is a general inflammation of the muscles and is associated with disturbed sleep patterns.

A thorough interview by a staff person will usually take between 10 to 20 minutes. This depends upon the skill of the interviewer and the talkativeness of the patient (which should have been determined at the initial phone call and scheduled accordingly). When the staff member has completed her interview of the patient, it will usually take only a few minutes to repeat her findings to you and for you to ask clarifying questions. With this approach, an extensive and sometimes rambling interview need not occupy the doctor’s time, allowing him to get right to the point. The patient can now be invited to the examination room where you can begin an informed examination using a systems approach.

Figure 2.

After discussing her findings from the initial interview with the orthodontist in private, the staff member turns the patient over to the doctor in the examination room.

Examination

The main focus of the examination is to
begin the process of confirming what was unveiled in the interview process. If your interview was thorough, the probability is high that you will already have a very good idea of what the patient’s problem is and how you are going to proceed with treatment. By using a systems approach, you can correlate what they have been saying with what you find during your examination. For example, if the patient complains of chronic "sinus" headaches with pain below the eye, you would expect to find some sensitivity in the lateral pterygoid muscle, since trigger points in this muscle will refer pain below the eye. You might also be looking for structural or occlusal disharmonies that would require the condyle on the affected side to be moved forward, since that would strain that lateral pterygoid muscle.

A systems approach is commonly used in medicine. It is nothing more than examining the patient in an orderly fashion according to functional systems. In a TMJ examination, you would start with an evaluation of the function of the joint itself, followed by the associated muscular, occlusal and skeletal system. The function of the cervical area could then be evaluated, along with the associated muscular system (many TMJ patients have concomitant cervical dysfunction) and the neurological condition of these areas could be evaluated, if indicated.

Joint function can be determined by evaluating all functional jaw movements as to maximum limits with and without pain. When the patient reaches maximum opening, can they open a little farther with gentle pressure on the front teeth ("soft-end feel")? This is usually diagnostic of a muscular problem. If their maximum opening is unyielding to pressure ("hard-end feel"), it indicates an internal joint problem (Figure 3). The smoothness and coordination with which movements are performed are also important. Small deviations back and forth reveal a lack of muscular coordination. Large deviations are more diagnostic of internal joint problems. Many times, a patient will be referred to the office with what appears to be an acute closed lock, even though they are able to make normal excursive movements. This is characteristic of a muscle spasm.

Figure 3.

The sounds generated by the moving joints are helpful to aide in establishing a diagnosis, but for the most part, unless you are dealing with an early click or contemplating joint surgery, they often have little effect on the actual treatment plan.

The muscular system is examined for feel, texture and the ability of the muscles to perform under load. Muscles are palpated to determine if they are hypertrophied,which is indicative of parafunction. They are also palpated for general soreness or discrete trigger points, again pointing to dysfunction. Palpation should be directed toward determining if the trigger points are those that would tend to refer pain in the same pattern that the patient described during the interview (Figure 4). This is how you can confirm your diagnosis. It is important to note that the less your examination findings correlate with the patient’s description of the pain, the more you need to be wary. This does not mean that you would not use a "diagnostic" splint - it means you should be more careful. You could still use a "diagnostic" splint, but be cautious with estimates of success or treatment time.

Copyright The Kinnie-Funt (K-F) System of Referred Pain of the Head, Neck, Face, Temporomandibular Joint Page 18

Since many TMJ patients also have cervical dysfunction, it is imperative that the examination include an evaluation of cervical mobility along with palpation of the cervical musculature. Forward and backward flexion, along with rotation, are evaluated in the same manner as the TMJs. The head can be rotated 45° and tilted to the same side while pressure is being applied to the top to test for nerve entrapment exiting the spinal foramina. Again, correlation of findings with the patient’s pain pattern is important. Splints can have a significant effect, either positive or negative, on cervical dysfunction, because a splint will change head posture. If an increase in cervical pain occurs when a splint is first worn, you need to reduce the time that the splint is worn and attend to the neck first (physical therapy or other referral).

For orthodontists, the easiest part of the examination tends to be the occlusal and skeletal system. However, besides the standard orthodontic evaluation, special care should be given to functional movements. Do they follow gnathological principles? Is cuspid guidance present, etc.? Be especially mindful of the patient’s facial pattern based on the mechanics. Is it a vertical or horizontal pattern? Where are the wear patterns on the teeth? What muscles would be affected by this structure? For example, the patient with a vertical facial pattern would have wear on the posterior teeth. They would tend to have a forward head posture which is related to the position of the mandible and the hyoid bone. You would expect the patient to describe pain in the back of the head caused by trigger points in the posterior cervical muscles. You would also expect pain in the frontal and maxillary sinus areas due to referred pain from the sternocleidomastoids and lateral pterygoids. You might expect pain behind the eye referred from a joint which is tender. Look at all the information you have gathered. See how it all relates!

Summary

By the proper use of staff and appropriate scheduling, the orthodontist can interview the TMJ patient efficiently and develop a tentative diagnosis (please feel free to call my office at [414] 886-9710 for a copy of the forms which we use). This diagnosis can then be tested by correlating the examination findings with the pain pattern of the patient, using a systems approach. By testing, the doctor can develop a more targeted treatment plan and more accurately estimate treatment time and costs. This improves not only patient satisfaction but also reduces stress and improves profitability.

Once the diagnosis has been made and tested, the process of treatment can begin. There are many different philosophies with different treatments. It is wise not to follow just one. It seems everybody is right and everybody is also wrong at times.

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