Re-testing helps patient and dentist

Case Example: Re-testing helps patient and dentist

A 19-year-old female was suffering from TMJ pain and severe bilateral (both sides) headaches of more than three years duration. The pain started after an auto accident, and she did not have any pain before the accident. A neurologist ordered a CT scan after the accident, but it was negative. She had been treated with several medications with no success and was involved in long-term litigation with her insurance companies.

The patient was extremely anxious and nervous during the clinical examination. She was going to be married in three or four months and was concerned whether she could afford treatment.
The physical exam found extreme tenderness over the left TM joint, and in several facial muscles. Jaw opening was restricted, and a click occurs in the left TM joint at 23mm. Severe crepitus was heard in the right TM joint upon movement. The patient had recently completed orthodontic treatment and was wearing an upper removable retainer and a lower bonded retainer. All teeth were present and in good condition. X-rays were normal, showing no bony abnormalities. A diagnosis of trauma-induced bilateral disc location without reduction (the disk is misplaced and does not move upon opening(see Glossary)

The TMJ Scale was given by the dentist to corroborate these findings and to measure the severity of symptoms before treatment. All areas were elevated, except for the bite feeling off and Non-TMJ.

Repositioning splints were placed on the upper and lower teeth and the patient was instructed to wear the upper appliance only at night and the lower one during the day. She was then treated for three months with another type of splint. The patient was checked monthly, and after three months of treatment she said she felt 95-100% better. Another TMJ Scale was administered by the dentist. Some improvement was found, but many of the areas were still elevated. He immediately noted that her answers to the TMJ scale did not agree with her statement that she was much improved. When confronted with this discrepancy, she said that she was to be married in a few weeks, and had not reported some pain and teeth clenching.

Treatment continued and five weeks later she again reported a 95% improvement. She had been married, and the apartment complex she and her husband managed had been burned by an arsonist. A third TMJ Scale was given, and again the results were at odds with her verbal report. She then admitted that she needed a release from treatment to complete a settlement with her insurance carrier.

The patient was advised that it was in her best interest to finish treatment. She consented and within two months she again reported complete relief from pain. At this point she had a 55mm opening (considered normal) and no joint sounds. A final TMJ Scale report which showed most areas below significance confirmed her verbal report and she was considered completed.
Comment: This case demonstrates how the TMJ Scale can be used to monitor treatment progress, and to help the dentist and the patient to determine when treatment should be concluded.

(Published in the Journal of Clinical Orthodontics, 1991)

To see an example of the TMJ Scale Report-Patient Version go to http://www.tmjscale.com/examplereport.html

To read more about the TMJ Scale and how to take the patient version of this test click http://www.tmjscale.com/tmj-scale-description.html

Chronic TMJ Pain and Stress

A 21-year-old white female was experiencing chronic facial pain and clicking in the left TM joint that made chewing difficult. Her doctor thought that orthodontic treatment was necessary, even thought the patient had no specific concerns about the appearance or functioning of her teeth. The problem had been present for 8 years. During this time she had multiple adjustments to her bite. An orthodontist constructed an occlusal splint designed to adjust her bite. When that did not bring any relief, she was referred to a pain clinic for evaluation and treatment. During the initial interview, it was discovered that stress made the problem worse. The patient was under considerable stress in work and family environment. She also said that she was sometimes aware that she clenched her teeth.

Her TMJ Scale Report noted significant overall TMJ symptoms and pain, joint noises and functioning problems, limitation in jaw opening and the impression that the teeth did not fit together properly. Emotional factors were not elevated, but a significantly high stress level was found. The report also indicated that clenching and sore teeth in the morning (a sign of jaw clenching and/or grinding during sleep) were found.

The physical examination found facial muscle tenderness, but not the joint clicking she had reported, even when the jaw was forced open to 45mm past the 32 mm that was comfortable to the patient. A diagnosis of MPD brought on by stress and clenching was made, with a minor click due to an anterior (to the back of the joint) disk displacement. The treatments prescribed were physical therapy, biofeedback to reduce stress, and Flexeril, to control pain.

Comment: The TMJ Scale (and the patient) reported joint noises, but the physical examination did not. This is because TMJ symptoms can be intermittent, present one day, but not the next. Because the TMJ Scale asks about recent symptoms, not just symptoms present now, it augments the physical exam and provides data that might otherwise be missed. This case also points out the importance of determining whether stress is an issue, and not just looking for a physical problem, as the patient's doctors first did.

(published in the TMJ Scale Manual 1987)

To see an example of the TMJ Scale Report-Patient Version go to

http://www.tmjscale.com/examplereport.html

To read more about the TMJ Scale and how to take the patient version of this test click

http://www.tmjscale.com/tmj-scale-description.html