Download PDF

Screening orthodontic patients for temporomandibular disorders

Diagnosis
First Online:
Received:
Accepted:
  • 326 Downloads
Part of the following topical collections:
  1. Orthodontics

Abstract

At a minimum, a screening evaluation for TMDs should be included as a component of the initial orthodontic evaluation process. It is also important for orthodontists to discriminate between major (significant) and minor (insignificant) signs and symptoms of TMD if they are discovered during the screening. If the patient has significant TMD issues, the orthodontist must decide whether to take on the responsibility for managing them prior to initiating orthodontic treatment. If not, an appropriate referral must be made. Furthermore, orthodontists must respond appropriately when a patient is referred specifically for the treatment of TMD issues. In this circumstance, it is important that communication with both the patient and the referring dentist follow current scientific concepts about TMD–orthodontic relationships. If TMD signs and symptoms arise during orthodontic treatment, orthodontists must be cognizant of proper procedures. Because there is some potential for the development of TMD issues after orthodontic treatment in a segment of their population, it is important for orthodontists to react appropriately in these circumstances.

Keywords

Orthodontist Temporomandibular disorders (TMDs) Screening TMD–orthodontic relationships 

Quick reference/description

The American Academy of Orofacial Pain (AAOP) defines temporomandibular disorders (TMDs) as “a group of musculoskeletal and neuromuscular conditions that involve the TMJs, the masticatory muscles, and all associated tissues”.

Routine screening of all prospective orthodontic patients for the presence of temporomandibular disorders (TMDs) is needed because the following clinical situations can occur in orthodontic practice:

  • The orthodontist may have a patient referred specifically for TMD issues.

  • TMD signs and symptoms may arise during orthodontic treatment.

  • A completed patient may develop TMD after orthodontic treatment.

Oro-dental screening includes (1) caries history and current dental situation, (2) periodontal history and current findings of concern, (3) oral cancer screening and soft tissue examination, and (4) an evaluation of the orofacial region with emphasis regarding the temporomandibular joints (TMJs) and associated musculoskeletal structures. Screening protocols and forms are used to record various major and minor findings obtained during the screening exam.

Symptoms

Table 1 lists the symptoms of TMDs.
Table 1

History of chief complaints

Symptoms

Questions to be asked

Pain

The location of the pain(s)

Date of onset

Event onset (spontaneous or stimulus induced)

Quality

Frequency

Duration

Intensity (based upon a numeric rating scale of 0 = no pain to 10 = the most extreme pain, or a visual analog scale using a 10-cm line labeled at one end with “no pain” and at the other end with “most extreme pain”)

Factors that alleviate, aggravate, or precipitate the pain; changes over time; previous treatment results; and any associated issues

Patient should be asked for any history of nondental facial pain

TMJ clicking or popping

When did the clicking start?

Has it become more frequent or louder?

Is it associated with any pain?

Does the jaw ever get “stuck” in trying to open or close? Did the patient ever report it to a physician or dentist?

Functional difficulty

Patients should be asked if they have noticed a limitation in their ability to open their mouth widely? Was it always there or it has been developing over time?

Ask if normal functions like chewing hard food, singing in a choir, yawning widely, chewing gum, or sitting through a long dental appointment produce fatigue and pain; if so, does this symptom linger afterward or go away fairly quickly?

Dental history

The dental history should include information regarding previous dental disease, treatment, and habit history (awake and asleep).

Medical history

Medical history should include information regarding any previous surgery, hospitalizations, trauma, illness, developmental and acquired anomalies, sleep disorders and sleep-related breathing disorders, allergies, and medication usage (including prescribed, over the counter, herbal and vitamin supplements, and illicit drug use).

Psychosocial history

Psychosocial history includes a discussion of social, behavioral, and psychological issues; occupational, recreational, and family status; litigation, disability, or secondary gain issues.

Comorbid conditions are frequently found in TMD patients, such as certain headaches, affective disorders (anxiety and depression), and nonorganic (functional) disorders such as fibromyalgia, irritable bowel syndrome, interstitial cystitis/bladder pain syndrome, chronic pelvic pain, and vulvodynia.

Clinical examination

A thorough physical examination consisting of inspection and palpation of the oral cavity, TMJ and adjacent structures with adjunctive use of auscultation should be performed (Table 2).
Table 2

Physical examination

Inspection

Inspection of the head and neck

Orthopedic evaluation of the TMJ including intracapsular sounds

Assessment of the cervical spine

Masticatory and cervical muscle evaluation

Evaluation of the cranial nerves for neurovascular, neurosensory, and motor problems

Observation of mouth opening, lateral excursions, and mandibular protrusion

An intraoral assessment (hard and soft tissues)

Palpation

Palpate to assess clicking, popping, or other TMJ noises

Palpation of the masticatory muscles and both TMJs for tenderness/pain

Palpate adjacent structures

Measurement of mouth opening, lateral excursions, and mandibular protrusion

Auscultation

Check for clicking, popping, or other TMJ noises

Different joint sounds can be observed during the clinical examination of the TMJ. There may be a single click, which is often louder on opening and softer on closing (reciprocal click), or there may be multiple clicks in some cases. If the sound is a grating (crepitus) noise, the patient should be asked about a history of arthritides in other joints; if the TMJ is the only affected joint, questions can be raised about previous painful episodes in that area.

Diagnostic tests

To develop a definitive diagnosis and/or provide appropriate management, adjunctive tests may be required. These tests include:

  • Dental imaging (bitewing, periapical, and panoramic radiographs) to rule out dentoalveolar pathology.

  • Medical imaging (computerized tomography, cone-beam computed tomography, magnetic resonance imaging, radionucleotide, and ultrasonography) to evaluate the TMJs.

TMJ imaging is usually done when the history or examination, or both, is indicative of a recent or progressive pathological joint condition; significant dysfunction or alteration in range of mandibular movements; or significant and often sudden changes in occlusion (anterior open bite, posterior open bite, and mandibular shift). Other adjunctive tests to be considered are diagnostic anesthesia and serologic testing.

Procedure

The orthodontist must be prepared to deal with patients who present with orofacial pain symptoms. TMD signs and symptoms can be managed at three stages: at the time of presentation, during treatment, and after treatment (Table 3).
Table 3

Protocol for the management of TMD signs and symptoms within an orthodontic practice

At time of presentation

1. If patient has signs and symptoms of TMD, then the patient should be informed that orthodontic treatment will not resolve those problems

2. Current TMD signs and symptoms should be noted, and a full TMD history and clinical examination should be undertaken and recorded

3. If the existing TMD is acute and severe, the commencement of orthodontic treatment should be postponed until the condition is either resolved or stabilized

During treatment

1. Acknowledge and recognize the signs and symptoms of TMD

2. Reassure and educate the patient that TMD is not necessarily a progressive problem and in most cases symptoms will improve over time with conservative treatment

3. Active orthodontic treatment should be discontinued, and TMD signs and symptoms should be managed by either the orthodontist or an expert TMD colleague

4. Once signs and symptoms have been alleviated or controlled, active orthodontic treatment may be resumed with consideration to modification of treatment (reduction of forces on headgear, remove or lighten elastics, use of oral TMD treatment appliance)

After treatment

The patient should be monitored for signs and symptoms throughout the retention period. If symptoms arise, appropriate management should be provided

Previous and current TMD screening forms or recommended protocols

Screening forms are useful screening instruments for detecting TMD problems in the general dental patient population. The excellent levels of reliability, sensitivity, and specificity demonstrate the validity and usefulness of this instrument in any clinical office setting.

A structured questionnaire for screening all dental patients for the presence of TMD was first presented in 1982. In 2011, the following short (three-item) and long (six-item) versions of a newly developed TMD screening form were developed and validated (Table 4).
Table 4

TMD screening instrument

Differential diagnoses to be considered during TMD screening

Other orofacial pain disorders.

Various types of headache disorders.

Remember: Signs and symptoms associated with non-musculoskeletal sources in the orofacial region (neurologic, neurovascular, neoplastic, and glandular) are often similar to those arising from TMDs.

Pitfalls and complications

  • In some cases, even with expert care, the patient may continue to have low-level or recurrent TMD symptoms.

  • TMDs are complex musculoskeletal pain disorders that share many characteristics with other somatic pain disorders, making diagnosis complicated.

  • Pain and/or dysfunction of TMJ can be coincidental or might be a response to the orthodontic treatment forces, which creates difficulty in identifying whether the ongoing treatment is the cause.

  • Chances of developing TMDs are greater in adolescent orthodontic patients than in adult patients.

  • There is some potential for the development of TMD issues after orthodontic treatment, but they generally are not caused by that treatment.

Further Reading

  1. 1.
    Greene CS, Klasser GD (2015) Screening orthodontic patients for temporomandibular disorders. In: Kandasamy S, Greene C, Rinchuse D, Stockstill J (eds). TMD and orthodontics: a clinical guide for the orthodontist. Springer, Cham, p. 37–47. doi: 10.1007/978-3-319-19782-1_3
  2. 2.
    American Academy of Orofacial Pain (2013) Diagnosis and management of TMDs. In: De Leeuw R, Klasser GD (eds) Orofacial pain: guidelines for assessment, diagnosis, and management, 5th edn. Quintessence, Chicago, p. 129–130Google Scholar
  3. 3.
    Okeson JP (2013) History of and examination for temporomandibular disorders. In: Management of temporomandibular disorders and occlusion, 7th edn. St. Mosby, Louis, p. 170–221Google Scholar
  4. 4.
    Leite RA, Rodrigues JF, Sakima MT, Sakima T (2013) Relationship between temporomandibular disorders and orthodontic treatment: a literature review. Dental Press J Orthod 18:150–157CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Louisiana State UniversityNew OrleansUSA
  2. 2.University of Illinois at ChicagoChicagoUSA

Personalised recommendations