Determining TMJ Health: what to look at during the initial exam
Posted by: Dr. Andrew Cobb
What things do we look at in the initial exam to determine TMJ health and maybe what do we look at periodically to also assess joint health?
I think the beauty of this whole process is that the complete examination (taught by The Dawson Academy) and the way it is laid out gives us the ability to thoroughly examine our patients and to determine a couple of things.
The steps to get to the diagnosis
The big picture of what is going on in the patient's mouth is at the end of the examination. There are a couple of key questions that we need to answer:
- Is this a general or a specialty patient?
- If it is a specialty patient, are they symptomatic or asymptomatic?
- Do they have muscle or joint issues?
We need to be able to make that diagnosis from muscle or joint. If it is joint, is it a partial or a complete issue that we are worried about, or is it possibly degenerative joint disease? So we need to go back and look at the entirety of the examination.
The preclinical interview
We need to ask what brought the patient there; what is their past history? What has their dentistry been like in the past? These questions are all very important. The seven questions included in the examination process are designed to give us key information. We can have a really good idea of whether we have a symptomatic or an asymptomatic patient. If it's symptomatic, is it muscle or joint? If it is joint, is it a partial or a complete disc dislocation? That's simply by asking seven really important questions.
Look for soreness, wear and breakdown
We are going to look at the muscles, and we are going to palpate the muscles in order to determine if they have muscle issues or soreness. If they do, that leads to a potential occlusal muscle issue. Do we have interferences or hyperactivity of the muscles? From that information, we know that there could be wear and tear on the teeth, which is going to cause breakdown of the system.
Range of motion is important. Is it normal? Is it restricted? Do we have deviations on opening or closing? All of this information is necessary to determine if we possibly have a muscle problem or a potential joint issue. Every time we think about joint issues, we automatically think is it a partial disc dislocation or a complete disc dislocation. Our treatment options vary with that answer.
Centric relation load testing is extremely important in determining TMJ health. Peter Dawson has been talking about this forever. Can we load the joint? Mild, moderate, and firmly? Are there any signs of tension or tenderness? Tension pointing to muscle issues. Tenderness pointing to disc intracapsular disorders, complete disc dislocations.
Using a doppler
We're going to listen to the joint with a doppler. What information does that give us? We're listening to the medial pole and the lateral pole. Medial pole is where centric relation lives. There are only three things that we can hear when we use the doppler.
- It's quiet, which gives us information that the disc is there and it's intact.
- A click or a pop, meaning the disc was off and it recaptures.
- Crepitus, and that crepitus then occurs when the disc is locked off, and we hear that staticky noise.
If they do that in rotation and translation and we interpret that data, we have great information on what we think might be going on inside of that joint. So all of those things give us great, great information, again, on if it's a symptomatic or asymptomatic patient and, again, if it's disc, is it partial or complete?
Signs of Instability
What if we have a patient that maybe we haven't gone to treatment? Maybe it was an asymptomatic click and there weren't really any other signs of instability, and maybe they're in our hygiene or recall system. What can we do periodically to check those patients? We should be training our hygienists to be doing this. What are things that we could look at that are going to show signs of instability or breakdown?
So we can look at joints or the teeth for:
Evaluate the treatment
Photography is a great way to compare in between, and our hygienists can do that. We can look at the muscles. Are the muscles sore? Are we getting headaches or problems that we didn't have before? Are the joint noises changing or getting worse? What if we had a click but now the click is gone? Did that patient get better, or did they get worse? Well, our worry would be that they got worse. They went from a click to a closed lock. What if it was a lateral pole patient that happened with that the click disappeared and that patient now needs some dentistry? Well, that's a risky patient because with their progression of the disease, if they're off the lateral pole, they're locked off now. What if it's slowly starting to slip off the medial pole and we do some dentistry without addressing this? Well, they have the potential to happen to have complete disc dislocation which is a much more complicated problem.
The initial completed diagnosis and what is going on with those patients is hugely important. Periodic things we are going to look at in the muscles, joints, and teeth. But if we start to recognize changes, the sooner we can correct the issues and the easier and the less invasive the dentistry. Sometimes by delaying things, we are only setting ourselves up for more complicated solutions.
To learn more about diagnosis and the complete exam, register for Functional Occlusion - From TMJ to Smile Design.