Diagnostic Criteria for TMD,

DC/TMD
Hanzara Panol
Objectives

▪ Discuss the clinical protocol and assessment instruments of DC/TMD:

▪ Axis I: questionnaires, examination form, examination protocol,
decision tree and diagnostic criteria
▪ Axis II: questionnaires (Graded Chronic Pain, JFLS-8, JFLS-20, PHQ-4,
PHQ-9, GAD-7, PQH-15, Oral Behavior Checklist) and scoring manual
Symptom Questionaire
Headache
Locking
Demographics
• Marital Status
• Ethnicity
• Race
• Level of Education
• Household Income
Add a Slide Title - 4
 Patient Management

Patient Position
Examiner Position
Jaw Posture
Replacement Prostheses
Removable appliances
Instructions to the Patient
Completing the Examination

Sequencing of examination procedure-Section 5

Complete all items- “RF”
Repeat Examination items
Physical barriers to examination
Measurements and Movements

▪ Ruler Preparation
▪ Millimeter measurements
▪ Measures of ROM
I. Vertical Movement
II. Lateral Excursion
III. Protrusive Movement
 Movement even with pain, but Pain free opening
 Movement without guidance, but Maximum Assisted Opening
Classification of Anatomic Structures

▪ Problem: Difficulty discerning structure

A. Identify area
I. First patient point to location
II. Mobility tests: ”paint “
III. Examiner touches area
IV. Examiner touches uncertain areas
B. Classify Structures
C. PA, Muscle Margin, Dynamic movement, Intra-oral, Referred pain
D. Decide and Record
Verification that reported history of pain is in
TMD structures

▪ Pain location history

▪ Patient inquiry-DC/TMD Symptom Questionnaire and Examiner
Confirmation of Pain and Headache Location
▪ Interactive Evaluation of pain location by history
Palpation

▪ Select Site: Masseter and Temporal

▪ Basic Screening: Initial contact-Ramp phase-steady force phase
▪ How many fingers
▪ Simultaneous bilateral palpation
▪ Palpation Duration
▪ Palpation calibration
▪ Procedure
▪ Confirmation of pain absence
Familiar Pain and Familiar Headache

▪ Pain that is “similar” or “like the patients pain, regardless of its

intensity, in the same anatomical region within the prior 30 days
▪ Affected by location, temporal characteristics, and intensity
▪ Verify Headache history: review section on Symptom questionnaire,
inquire about headache location as first part f the examination,
inquire if patient reports familiar pain into temporalis muscle.
▪ Headache vs Pain
Referred Pain

▪ Patient reports pain beyond the boundary of the muscle or joint

being palpated
▪ Localization, ask if pain was felt anywhere else, and to please point
to the area
▪ Spreading Pain: Pain that extends beyond the area of nociceptive
stimulation but not beyond the boundary of muscle
 Description of Procedures

▪ Examiner confirmation of Pain and Headache Location

Have the patient point at the area rather than telling or naming, patient
is oriented to area of interest and examiner confirms anatomical
structure.
Scope of Examination: Head and face
Procedure

▪ Identify areas of interest via light touch, but not naming the areas
▪ Pain: ask patient if has experienced pain in the areas within the last
30 days
▪ Headache: Ask patient to show all location of h/a experienced in the
last 30 days
▪ Assess pain locations throughout exam and add as pertinent
Incisal Relationships

▪ Incisors are stable landmarks fro ROM in vertical and horizontal movements
▪ If mutilated use nasopalatine papilla as landmark, or a lateral, in the mandible use
an estimated mudline
▪ Use tight maxillary incisor or left if not meeting criteria
▪ Reference line-overbite, draw horizontal line on mandibular teeth
▪ Reference line –midline between maxillae and mandible, if less than 1mm
discrepancy not considered, of >1mm
1. Measure distance between two midlines, round off, and record, note deviation
side
2. Draw a vertical line on labial of maxillary and extend down onto mandibular,
lateral movements measured between these two lines
3. Select maxillary midline and mark labial of apposite mandibular tooth
Opening Movement
Lateral Excursive Movements
TMJ noises during movement
E1-Confirmation of Pain and Headache
Locations
E2-Incisal Relationships
 E3
Opening
Pattern
 E4
Open and Close Movements
E5-Lateral and Protrusive
Movements
E6-Noises during Open and Close Movements
 E7 TMJ Noises during Lateral and Protrusive
Movements

▪ Place back teeth together, open slightly, and move jaw right as far as you
can , even if painful, move your jaw back and place your back teeth
completely together
▪ Repeat 2 more times
▪ Do it to the left side and repeat 2 more times
▪ Do it asking to move jaw forward and repeat 2 more times.
▪ To Dx disc displacement with reduction require presence of either a click
during both open/close or click during one open or closing movement
paired with a click during any of protrusion, rt lateral or lt lateral
▪ Ask for pain, location, confirm location and type of noise, and record
 E8- Joint Locking

▪ Can you unlock your jaw?

 E9-Muscle and TMJ Pain with
▪ Select coverage method for palpation –where every
part of the muscle is palpated
▪ Select time duration for stimulus
▪ 2 seconds-efficiency and ignoring referred pain
▪ 5 seconds to minimize false negatives diagnosis of
referred pain and to identify hyperalgesia
Masseter Palpation
Temporalis Palpation
E10-Supplemental Palpation Sites

• Posterior Mandibular Region

• Submandibular region
• Lateral Pterygoid
• Tendon of the Temporalis
 Days Points
0-1 0

2 1

3-5 2

6+ 3

Grade Label CPI Disability

Points
0 none 0 N/A

I Low intensity, <50 <3

w/o disability
II High I, w/o >50 <3
disability
III Moderately N/A 3-4
Limiting
IV Severely N/A 5-6
Limiting
Scale NOLIFETI SE CHRONIC SE
ME TMD TMD
Mean Mean
Mastication 0.28 0.02 2.22 0.13
limitation

Mobility 0.18 0.02 2.22 0.13

Limitation

Verbal/emotion 0.14 0.02 0.72 0.10

al expression
limitation
Global 0.16 0.02 1.74 0.11
 References

▪ Axis I: questionnaires, examination form, examination protocol,

decision tree and diagnostic criteria
▪ Axis II: questionnaires (Graded Chronic Pain, JFLS-8, JFLS-20, PHQ-
4, PHQ-9, GAD-7, PQH-15, Oral Behavior Checklist) and scoring
manual