TMJ Case Studies – True stories of the use of the TMJ Scale to help diagnose a patient

   

Case 1: Extreme jaw pain with clicking and popping

Case 2: Undetected brain tumor

Case 3: Sports injury

Case 4: Facial pain is not always “TMJ”

Case 5: Pain with jaw locking open

Case 6: Ringing or buzzing in the ear

Case 7: Mainly a muscle problem

Case 8: Chronic pain and stress

Case 9: TMJ complicated by neurological disorder

Case 10: Re-testing helps patient and dentist

Case 11: Graduate student with stress

Case 12: Whiplash injury

Case 13: “TMJ” and depression

Case 1: Extreme jaw pain with clicking and popping

A 16 year old white female in northern Pennsylvania was experiencing extreme jaw pain on both sides of her face near the ears in 1989. She had orthodontics for straightening her teeth six months ago. She had been experiencing non-painful clicking and popping in both ears for 18 months. She had not had any accidents or trauma to her head or neck. The pain had been getting worse the last few months, and she could not open her mouth wide without pain and was having problems chewing. This person took the TMJ Scale and the results indicated she had a TMJ problem. The report showed she had symptoms which were in the 64th percentile compared to other TMJ patients, with static pain, pain on pressing the face muscles, inability to move the jaw all the way, and a mechanical problem within the TM joint. She did not have a non-TMJ problem, and her stress scale was not above average. With this information she was seen by a dentist specializing in TMJ and had a physical exam and x-rays. She was diagnosed with “chronic disk displacement without reduction,” which meant that the disk which cushions the jaw as it connects to the cranium was out of place, cause her not to be able to open her jaw more than a little. She had a splint made for her, a soft rubber mouthpiece that fit over her teeth. She wore this for three months and it slowly moved the jaw back a little bit to “recapture” the disk into the correct position. Then she wore another type of splint for three to move the jaw slowly back into its original position. During the last six weeks, the appliance was worn only at night, as she gradually got back to normal. She reported feeling 100% better. The dentist then asked her to take another TMJ Scale. The results showed that instead of being at the 64th percentile for TMJ patients, her symptoms were below the 1st percentile. All the other scales were now well below average. The TMJ Scale had helped her to decide to seek treatment for her TMJ problem, helped the dentist to confirm his diagnosis, and then demonstrated that the patient had achieved a good result. (published in the Journal of Craniomandibular Practice, 1990)

 

 

Case 2: Undetected brain tumor A 51 year old white female was referred to a TMJ dentist in North Carolina in 1990 for suspected TMJ. She reported dull aching in both ears and soreness around the TM joint and facial muscles. Pain was always worst on the left side. She thought she might have an ear infection, but her family doctor and an ear, nose, and throat specialist found no problem in the ears. The patient had a history of ovarian cancer and arthritis in her right knee. A sister had lupus and another sister had died of rheumatoid arthritis. Her pain was described as “dull” and was not helped by ibuprofen or acetaminophen. The physical exam showed a normal jaw opening and no clicking or popping was noted with a stethoscope. When her masseter muscles (main jaw muscles) were pressed, some soreness was found. The condyles (the part of the mandible or jaw that fit into the cranium) seemed to be slightly misplaced. The dentist gave the patient a TMJ Scale to document her symptoms and screen for other problems. The TMJ Scale report indicated a “borderline” TMJ problem, with above average pain and joint problems. As with the clinical exam findings, range of movement was not found to be abnormal. However, the Non-TMJ scale was borderline, indicating the possible presence of another disorder which was different from TMJ. Further discussion with the patient revealed a deep concern about a possible spread of the earlier cancer. Magnetic Resonance Imaging (MRI) was prescribed, to include all areas of the head. The results confirmed a diagnosis of dislocation of the condyles, and the ear canals were normal. However, the brain imaging revealed a meningioma (tumor) in the left side on the brain stem. Treatment for the TMJ problem was halted while the patient was referred to a neurologist. In this case the TMJ Scale’s Non-TM factors scale led to the suspicion that something besides TMJ was present, and helped to justify the need for an MRI. (Published in the Journal of Craniomandibular Practice, 1991)

 

Case 3: Sports injury An 18 year old male in Indiana suffered a facial injury during a basketball game in 1995. Shortly after the injury he could not open his left jaw joint and had pain on both sides of his jaw, pain in his ear, and headaches. He completed a TMJ Scale, which showed he probably had a TMJ problem, with symptoms worse than 65% of TMJ patients. The report also indicated he had elevated pain, internal joint problems, and limited jaw opening ability. The Non-TM scale was not above average, and stress was not elevated. He saw a TMJ local dentist who prepared a soft splint, which he wore over his bottom teeth for five months. After that time, he only wore the splint during sporting events, as directed by the dentist. After five months the patient was asked to take another TMJ Scale by his dentist. The second report, which according to the dentist, “displays the dramatic improvement reported by the patient. His overall percentile rank fell from 65% to 8%, and all of the other scales. The dentist also reported that the TMJ Scale demonstrated that treatment had been successful, “and provided data to both the patient and insurers that Maximum Medical Improvement had been attained.” (Published in the Functional Orthodontist in 1996)

 

Case 4: Facial pain is not always “TMJ” A 48-year-old married white male was experiencing headaches and facial pain. He had a history of arthritis in his cervical spine (upper spine near the neck). He had been treated with medications, including Sansert and Cortisone. He had seen many doctors, dentists, and chiropractors for his problems, but found little relief. His headaches awakened him from sleep and were accompanied by redness and tearing of the eye and a stuffy, running nose. Drinking alcohol brought on the headaches. He was experiencing a great deal of stress from these problems, and was having difficulty sleeping. He was given a TMJ Scale to help diagnose his problems. He was classified as ‘borderline’ for overall TMJ symptoms, indicating the possible presence of a TMJ disorder. He reported significant pain and pain on pressing the facial muscles and the TM joint. The TMJ Scale Report indicated he did not have significant jaw joint noise or pain, and did not have problems with opening and closing his mouth and the teeth fitting together. This patient did indicate a high level of emotional problems, and his answers indicated he was predisposed to develop a chronic problem. The Non-TMJ problem area was elevated, suggesting that a non-TMJ illness was present. The TMJ Scale results and a physical examination suggested that the primary problem was not TMJ, but cluster headaches with secondary myofascial pain. A sphenopalatinate block (a local anesthetic administered directly through the nose with a thin rod to a nerve near the sinuses) during a headache completely relieved the pain, confirming that the pain was vascular(related to blood vessels) in origin. The patient was treated with physical therapy and TENS, transcutaneous electrical nerve stimulation. Two months later he was headache free. There was some ‘mild’ facial pain and ‘moderate’ muscle tenderness, but the patient was not concerned and felt he could treat these symptoms with aspirin. A follow-up TMJ Scale showed that lower levels of pain were still present, and non-TMJ disorders were no longer significant. Comment: This case illustrates that facial pain is not always TMJ, and that other non-TMJ factors need to be considered during examinations and diagnosis. The TMJ Scale in this case helped to point out that the patient did not have TMJ. (Published in the TMJ Scale Manual, 1987)

 

Case 5: Pain with jaw locking open A 31-year-old white female experienced facial pain on the left side, clicking and popping in the area of the TM joint, and the feeling that the joint was going to lock. This woman had a history of hypermobility (excessive opening) of the TM joints resulting in an open lock, where she could not close her jaw. In one case, a trip to the emergency room was needed to get her jaw closed, and she twice had surgery. Even after the surgery she felt her jaw was going to lock again. She was medicated with Dolobid and Flexeril, but still complained that her pain severely interfered with many of her daily activities. The TMJ Scale showed a significant overall TMJ disorder, with elevations in pain, pain upon pressing facial muscles, joint noise and functioning problems, and limitations in jaw movement. The non-TMJ, stress, and emotional problems areas were not elevated, nor was the likelihood of developing a chronic problem. Comment: The TMJ Scale confirmed a diagnosis of muscle splinting (resistance to stretching) and capsulitis (inflammation of the ligaments in the jaw joint). This represents an example of joint and muscle pathology uncomplicated by non-TMJ disorders or psychological factors. (Published in the TMJ Scale Manual, 1987)

 

Case 6: Ringing or buzzing in the ear A 45-year-old white female was referred for tinnitus (ringing or buzzing) in the left ear and facial pain that had been present for the previous two years. She had first sought treatment from her family doctor and an Ear, Nose, and Throat specialist. Both doctors had told her nothing could be done. She then went to a periodontist who thought her problem might be TMJ. An arthrogram (dye injected into the TM joint and an X-ray taken) was performed on the left TM joint and showed a disk perforation. The disk is a small piece of cartilage that cushions the upper part of the jaw bone as it meets the skull. The patient was then referred to several dentists and told that surgical treatment was necessary. The patient and her husband both had psychiatric treatment for depression earlier. The TMJ Scale Report for this patient reflected elevated overall TMJ symptoms, as well as heightened pain, pain on pressing, joint noises, and the teeth feeling ill-fitting. In addition, emotional problems, stress and the propensity for chronic illness were all highly elevated. A physical examination confirmed that multiple facial muscles and the TM joint were painful to the touch, and that both joints produced clicking at about 15 mm of opening. Crepitation or joint grinding sounds were also noted. These finding, combined with TMJ Scale results, led to a diagnosis of MPD–myofacial pain dysfunction, anterior disk displacement with perforation and tinnitus (see Glossary) Comment: This is an example of multiple TM disorders complicated by emotional factors and stress. This patient was undergoing treatment with a TMJ specialist. (Published in the TMJ Scale Manual, 1987)

 

Case 7: Mainly a muscle problem A 22-year-old African-American female was experiencing pain on both sides of her face, and her jaw had been clicking and popping for some time. On many occasions in the past few months her jaw had become stiff. She reported episodes of pain and limitations in jaw movements which lasted from a few hours to several days. The pain had been present for 18 months, while the joint problems were experienced during the previous 12 months. Nothing remarkable was found in her medical history. She completed a TMJ Scale, and the report indicated a borderline overall level of symptoms, with slight elevations in pain and pain on pressing, as well as joint noises and function. Limitation on opening the jaw were borderline. Emotional factors, stress, and tendency for chronic illness were not elevated. A physical examination found mild tenderness to both masseter muscles (the large jaw muscles behind the mouth). Both TM joints were sore when pressed, and produced audible clicks when opened beyond 38mm. A panoramic X-ray revealed no bony abnormalities. A diagnosis of MPD, muscle splinting, and anterior disk displacement with reduction (whereby the disk slips off the condyle when the jaw is opened– see the Glossary) was made. Treatment was aimed at the primary MPD diagnosis, and was designed to reduce the pain. The patient was prescribed Flexeril, and was instructed to apply moist heat to the joint and to avoid tough and chewy foods for a period of several months. Comment: This represents a ‘typical’ TMJ case with joint noise most likely due to a partial oblique (sideways) displacement of the disk. The TMJ Scale helped confirm that the chief complaint of pain and opening limitation was primarily muscular in origin, as opposed to a mechanical problem within the TM joint itself. (Published in the TMJ Scale Manual, 1987)

 

Case 8: Chronic 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)

 

Case 9: TMJ complicated by neurological disorder A 33-year-old white female reported TM joint noise for the past two years, and that joint pain and noise was getting louder over the past year. The pain was described as being over the right TM joint and chewing muscles. Intermittent deep throbbing pain on the other side was also reported, and a distinctly separate type of burning pain was described as covering the right side of the face. She did not recall any specific triggering event for these pains. Her medical history included a thyroid condition which was under control without medication. The patient had other painful joints in her hands and neck, for which she was seeing a chiropractor. She had been treated by a dentist with an occlusal splint, which helped at first but was not helping now. The TMJ Scale Report showed elevations in every scale, both physical and psychosocial. Almost all of her facial muscles were reported to be painful, as well as her TM joints. She reported clicking and popping in the joint, joint locking, and grinding sounds. A non-TMJ disorder was also indicated. The physical examination found multiple pain sites, limited jaw opening, joint noises (although no crepitus or grinding sounds), and problems with the jaw fitting together. X-rays found significant degenerative problems (arthritis) to the right TM joint. Several unerupted teeth (not emerged, still in the jaw) were found, and it was noted that some teeth were missing. The primary diagnosis was arthritis of the right TM joint, MPD, and possible dysesthesia (a neurological condition in which the sense of touch is impaired, so they even a slight touch can cause severe pain). Comment: This is a good example of a complex clinical situation with multiple TMJ disorders complicated by the presence of psychosocial factors and a major non-TMD condition. (Published in the TMJ Scale Manual, 1987)

 

Case 10: 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)

 

Case 11: Graduate student with stress A 27-year-old female graduate student was experiencing intermittent neck and facial pain. She also noted that at times her teeth “did not come together properly.” She knew that she occasionally clenched her teeth and she was aware that she sometimes pushed her jaw forward to make it more comfortable. The patient first went to a dental clinic where she received an anesthetic injection to her left jaw. Good pain relief was achieved, but it only lasted for five days. Her medical history revealed that she had Osgood-Schlatter disease (a bone disorder in her leg). She also reported a history of frequent sinus and temporal headaches. She was a well-adjusted young female who was single, dating and enrolled in a graduate school program which she described as “stressful.” She completed a TMJ Scale, and her overall TMJ symptoms were significantly elevated. All of the physical scales were elevated, with the pain scale being the highest. Emotional problems were not above normal, but her stress score was elevated, consistent with her statements about graduate school. She consulted a dentist specializing in TMJ at a dental school in North Carolina. A physical examination found multiple pain triggers in her facial muscles and a sore area around her TM joints. Although the patient reported a history of grinding sounds, clicking and popping, none was found at the time. She also reported a single incident of her jaw locking open. The diagnoses were MPD, daytime clenching, TM joint capsulitis, and a possible anteriorly displaced disk. Since no reduction in the range of jaw motion, in was considered unlikely that she had a non-reducing anterior disk displacement. Comment: The TMJ Scale helped the dentist to make the diagnoses, since it confirmed that stress was a contributing factor. Since the patient’s symptoms were intermittent, symptoms that were not present at the time of the examination were noted for the record. (Published in the Journal of Craniomandibular Practice, 1988)

 

Case 12: Whiplash injury A 36-year-old white female was referred to a university pain clinic for evaluation of pain in her jaw and face. Her problem had started eight months earlier as a result of an automobile accident during which she sustained a “whiplash” injury and subsequent neck pain and stiffness. She also suffered from tension headaches. She had been evaluated by doctors with several different specialties, and had undergone neck traction, which produced pain in the teeth, jaws, and TM joints. She was evaluated by a neurologist who ordered CT scans of the head and neck, as well as an EEG. Occlusal splint treatment was started. She had not found any relief for her pain and was considering litigation at this point. As part of her evaluation at the university pain clinic, the patient was given a TMJ Scale, along with a physical examination. The TMJ Scale’s overall score confirmed she had a significant TMJ disorder. Pain and pain on pressing were elevated, as were limited jaw movement and the bite feeling off. No clicking and popping were found during the clinical exam, suggesting that jaw functioning was not impaired, and this was confirmed by the TMJ Scale. The Non-TMJ scale was also elevated, reflecting the tension headaches. X-rays found no evidence of bony abnormalities. The patient reported significant emotional problems, and borderline stress, probably reflecting the result of eight months of searching for a solution for her pain problems. A tendency for chronic problems was revealed, alerting the doctor to the possibility of chronic pain syndrome. It was noted that litigation issues can present problems in managing pain because they may reinforce “illness behaviors,” which may be quite unconscious on the part of the patient. The elevated stress scale suggested that stress may have been contributing to the tension headaches. The overall diagnosis was Myofacial Pain Dysfunction and tension headaches. Comment: This case describes the use of the TMJ Scale in a complex clinical setting, where many different specialists may be called upon to help a pain patient. The test helped to confirm the diagnosis, and suggest that other factors, such as stress and a tendency to chronic illness, may need to be considered. (Published in the Journal of Craniomandibular Practice, 1988)

 

Case 13: “TMJ” and depression A 74-year-old Native American woman was referred by a neurologist to a university pain clinic for evaluation of TM joint pain and limited jaw opening. The patient had a history of rheumatism and neurological problems. She was taking a wide variety of pain medications, steroids, and pills for a stomach condition. Pain interfered with all of her activities, and some signs of depression (loss of appetite, sleep problems) were evident. The patient had full dentures that were somewhat unstable. The TMJ Scale indicated the presence of a TMJ disorder, and all the scales were elevated, confirming that both physical and emotional problems were present. A non-TMJ disorder was indicated. A “panoramic” X-ray was taken and revealed flattened condyles, with a bony spur on the right side, and decreased joint space, possibly made worse by the ill-fitting dentures. A diagnosis was made of a bilateral (both sides) TM degenerative joint disease and MPD. Comment: The TMJ Scale helped to confirm the physical diagnosis and to point out that factors such as depression could play a significant role in the treatment of this patient. (Published in the Journal of Craniomandibular Practice, 1988)