Hello, this is Dr. Steven Potts. I am a dentist and I've been practicing 40 years almost in Middle Tennessee. I'm here today to talk a little bit about the evaluation of the temporal vendibular joint and how important that is to all aspects of our practice, whether you're doing restorative implants, dental sleep medicine, or whatever you're doing. I think this is a very valuable tool that's very simple, it gets overlooked quite a bit in restorative dentistry. With my practice now being focused mainly on TMD and dental sleep medicine, I see a lot of things from the restorative side that I didn't see as much many years ago as I was practicing. We'll go through some things here, and I think the biggest thing is first coming up with some questionnaires or some form to document what you find on these patients, that you're looking at or contemplating on treating for whatever aspect of dentistry there is. Then clinical steps to evaluate the joint, we want to look at those. Then we also really important, want to make sure the patient's informed of our findings. Sometimes what seems obvious to us, as far as someone's jaws popping or clicking or muscle pain, the patient really hasn't paid much attention to. The reason I say that is if you go and do a lot of extensive restorative or other types of dentistry, and the patient then becomes aware of something, and they're like, well, I don't remember my jaw used to pop, and you have documentation that you can say, yes, we went through this and you signed a form to say so. Those are some of the things we're looking at here, and being able to talk to the patient about consequences, treatment is not done, or if treatment is done, what are the possible side effects and different things as well. First thing in this is I want to look at some screening, and there's a lot of different ways you can create your own screening tool. I'm going to give you some guidelines that you can look at here and go from there with it. One of these, and this is a free download here, is a diagnostic criteria for temporal mandibular disorders. In that download, there is several different things you can utilize. It's about 45 pages, but not all that's questionnaires and things. There's one that we'll talk about first that's a little more involved here. This one here is basically 14 questions, and they divide it between pain, headaches, jaw noises, locking, opening, locking, different things that you can ask questions. Pretty straightforward, simple yes or no questions, and it gives you a pretty good idea upfront what is going on with the patient before you actually do an exam. Again, a lot of people come in and they have no idea. They think what is normal, we see as abnormal as far as joint noises and pain. We just want to be able to sit down, look at a lot of these things, and be able to have time to spend a few moments with the patient. Again, I'm talking about primarily patients. This can be done with all patients, but primarily those you plan on doing some dental work on. There's also a very quick screening tool. Now, this one, as you can see, is three questions, and it can be done by a team member. It can be done by an assistant or hygienist or somebody just to find out things that are going on in the last 30 days. This is also in that download that I showed you a moment ago. So get some information upfront before you start the process of the examination. It's always very helpful, and a lot of times those questionnaires will prompt other questions for you to utilize. And, of course, the AADSM has a questionnaire, if you're a member of theirs. Now, it goes into a little more detail also with the physical assessment as far as like Malapati scores, and if you had a PSG or HST, and a lot of different things that also can overlap with this because a lot of bruxism and TMD issues can be related to some breathing issues as well. So there's also forms there, and you can take all these, make up whatever form you think you're comfortable with. These are just some good ideas to look at. So what I'd really like to do is start with the examination findings. We'll look through different things with muscles and joints and then radiographical findings we look at. So we'll kind of divide this in different sections, and we'll discuss each section for you as well here. So I think the first thing, things you already should be doing or doing is when you have your dental examination, again, even if this is a hygiene patient or whatever the situation is, be sure to document. Look at things like arch form, cross bites, open bites, midline, is the midlines off, is there overjet, overbite, you know, crowding, procline, recline teeth, wear facets. Those are the kind of things we should be aware of regardless. This is to be part of our routine visit if they're in hygiene or your new patient exam and what you're trying to do for any kind of restorative work or dental sleep medicine, whatever that may be. Now, for me, I try to keep things pretty simple. Like I said, I do dental sleep medicine, mainly TMD now. Again, used to lots of restorative work, but for me now, I have a disposable mirror I use, a cotton tip applicator I use in different things we'll talk about a little bit, something to measure. We want to look at range of motion, overjet, overbite, left and lateral movement. So those are some things that you might need, some kind, again, this is a disposable or measuring tool I have. I have a periodontal probe and you can use measurements for that as far as overjet, overbite, but also a lot of times I'll get patients, again, I don't have a dental hygienist, if there's something kind of suspicious about lung levels, I may use a probe just to get them referred back to their general dentist for a cleaning or a periodontal evaluation, if there's gonna be some things that we're doing in our office. And then on the last part of the screen there, you see cheek retractors of whatever type, always very good idea to take retracted views and centric occlusion, right and left side at least. And that's just good documentation. You can do it with an intraoral camera or you can do it with a intraoral scanner, or you can do it with just a digital camera. I think that's always good to have. Patients do not remember things as well as we will, and we have the documentation, even if it's years later, patients coming back, go, I don't remember this, and you go, well, I've got a picture here, that was there several years ago, we talked about this. So it's just good to have the documentation there for anything you're planning on doing. And whether again, restorative or orthodontics implants or any of those things. So the first thing we try to do is look at the basic muscles, the head and upper neck area. And we try to start from the top, which is gonna be the temporalis muscle and we'll kind of move down from there. And so these are kind of the muscles that we look at that can give you a lot of indications on other issues with joints, tendons, muscles. And so you got the temporalis muscles you're looking at, we'll discuss those. The temporalis or temporal tendon, which is really something that can cause quite a bit of pain. The mastodons, deep and superficial, digastrics, sternocleomastoid, trapezius, and splenus capitis. So these are the kinds of muscles we're gonna go through. And I usually just talk to the patient for a minute about, I'm gonna go in and I'm gonna palpate these muscles and try to get some feedback. I try to use a consistent amount of pressure when you're touching different places, the head and neck area, you need to be kind of consistent on that. And so generally one and a half to two pounds of pressure on the muscles. So if you're doing the mastodon or the temporalis, and about one pound of pressure on the joint. Joint's usually a little more tender and I try to palpate bilaterally at the same time. And I wanna describe this to the patient as, okay, when I, cause I've done some examinations and I say, I'm looking for some tenderness of your muscles. And I'll get through and they'll say, well, nothing was tender, but they sure are sore. And I'm like, wow, I miscommunicated here. So let the patient know what you're trying to do. You're looking, you know, muscles should not be sore. Joints should not be tender or touched. So when you use tenderness, soreness, you're gonna touch these muscles and use that pressure. And I always try to tell the patient, and again, this is gonna vary from day to day, but one's a little bit of soreness or tenderness or pain, whichever way you wanna look at it. And three is a significant amount. And they're like, well, I don't know. Is it a 2.5? I just said, whatever you think it is, because if I do this again tomorrow, it's gonna be a little bit different. So we're just taking an overview of the muscles and joints in the head area, head and neck area. I used, to get an idea, if you haven't done this, you can get any kind of scale and place your fingers on it. You can see there's about two pounds I've got on this picture here. And depending on the muscle, if it's a temporalis muscle, you can probably use two fingers. The mastoid, you probably can use two fingers. Some of them, if you look at the deep mastoid, we'll talk about in a minute, you may have to use one finger. So you have to use your own judgment with the joints, you're probably using one finger. And of course, the pressure is gonna be a little bit less on the joint than it is the muscles. So starting with the temporalis, you got an anterior, posterior or anterior middle, excuse me, and posterior temporalis muscle. And they attach into the coronary process and part of the ramus there. Now, this muscle is a source of a lot of headaches, a lot of pain when we look at these things here. So looking at the temporalis muscle, a lot of times patients will come in and they'll say, well, I have, I asked, do you have headaches? And if they say yes, I'll say point. And then if they're pointing here, then I'm really a key to when I get the palpation to what to look for. Or sometimes they'll say, well, I have migraine headaches. And I ask, have you been diagnosed to have migraines? Or some people are self-diagnosis on that. So just get into the weeds a little bit with this. You know, and again, patients, sometimes if they say they do have headaches, then I try to divide that between, do you wake up with headaches or do you wake up and you're fine and by mid, late afternoon or early evening, you have headaches. I'm looking at maybe something going on at night versus daytime clenching that may be causing some pain. Trying to separate those two out is always very helpful in proceeding forward with this. So in the anterior belly, you can see I'm right next to that, right by the eye area here, right behind this area here. And this is a very frequent area of headaches. And again, when you ask patients, if you have headaches or something hurts, try to get them to use one finger because they'll point like this. And that doesn't really tell me if they're like this or like this, then I have a better idea what muscles I'm gonna be focusing on on this. So we start with anterior belly and then we'll move to the middle. And that's usually round above the ear area mainly. And I'll do both sides bilaterally and then we'll go to the posterior belly. And a lot of times, the anterior can be very tender and maybe the middle of the posterior is not or vice versa. So we just go through each one of these and I'm asking if there's anything there, if there is, rate it from one to three, three being the worst. So this muscle, very important muscle here, attaches into the temporalis tendon area. It's the temporalis tendon, which is part of the coronary process in the retromotifossa area. Now this tendon is again, a source of a lot of pain. And so we start looking at that. Sometimes people will come in and they will talk here, but they'll also talk in the general face area, which makes me wonder about the temporalis tendon. So you want to look at that. Now, Janet Travell has a book out that goes through all these little facial pains and trigger points and things. It's a very good resource to look at. But you can see by this drawing here that the temporalis tendon can be a source of pain all the way into the teeth, back to the ear area. So you really want to kind of define that and look at that as a source of discomfort if someone has a general face pain that they cannot seem to specify. And so the easiest way to do that, this one is best to palpate intra-orally, but I try to locate generally where I'm going to be extra-orally with my finger. And I use a Q-tip or a cotton tip applicator there versus my finger, just to get you get a better idea kind of where the coronary process is. And then from there, I kind of reach in up to where the temporal tendon is. Don't use as much pressure here. I would say probably about one pound because this can be very, very tender and you'll send someone out of the chair pretty quickly. So I'm just very gently touching that area. Now, this can be tender and it can be tender for a lot of reasons. Heavy clenching, it can be tender for if you made an appliance and the verticals open too much or you made implant dentures and you open someone too much. There's a lot of different reasons this muscle can get tender. So pay very close attention to that. So moving from there, we look at the master muscle and you notice here, there's two sections of this. You got the deep belly and the superficial belly and notice where the deep belly is in relation to the joint. So I have patients again, I'll come in and I'll say, it hurts and I say, where? And they'll point. So if they're not pointing right in the ear and they're a little bit in front of that, I'm already a little bit suspicious that this may be a deep belly part of the master's tender. So we'll look at these. And again, this muscle attaches in the zygomatic arch area and goes down into the ramus and the angle of the mandible. And again, a muscle that can be involved in a lot of discomfort, especially in heavy clenching and overuse here. So looking first at the superficial, I, again, this is one of the few that you can actually palpate extra orally if you want to. Usually it's more toward the attachment toward the ramus of the mandible where this may be tender. You can see where I'm pointing here with a cotton tip applicator and my finger. If you wanted to on this muscle, you could go intraorally, go the long length of the muscle from the origin to the attachment here. And it just shows me doing this here, trying to palpate if there's any tenderness. Generally, it's not as much in the body as it is more toward the attachment, but I'm quickly just running my hand down there to ask that. Also, then I move back to the deep master. And again, it's a little more confined. It's very close to the joint. So you have to be really cautious about that and make sure that it could be the joint involved and the deep master involved. But we're looking right now at muscles. So I would look at the deep master. And again, when you palpate this, you can get a pretty good idea because if I'm touching the deep master and I go, is that tender? And they go, yeah, that really is. I quickly will get into the joint but just kind of move back to the joint and say, is that tender? Make sure I'm not confusing where the pain is coming from. And again, it can be both places, but a lot of times it's just the deep master. You touch here and they're not tender at all, but we'll get to the joint in a moment here. But this can mimic joint pain. So pay real close attention to the deep master muscle when you're doing this examination. Now, there are other muscles that can be affected in the anterior and posterior digastric muscles. You know, they stabilize the hyoid during swallowing and pressing the mandible. And it also, the posterior elevates the hyoid and depresses the mandible. And you're probably thinking, why am I so concerned with this muscle? People that generally have a deep overbite and they clench a lot. Some of them, not many, but there's some that will rest their tongue between their teeth because it makes their, actually their master muscles feel better. But if they keep the tongue at that higher level, it will get very tender through the anterior and posterior digastric. Also people that have any other tongue issues, maybe tongue thrusting, or some people say I rest my tongue or try to push my tongue on the roof of the mouth, they will end up with some tenderness in the anterior digastric more so even in the posterior. So I'm always looking at that. And if that's tender, then I'm gonna ask questions about tongue movement. It just gives me another little hint. And I find a lot of times there is some correlation between that and the amount of movement they're doing, abnormal movements with their tongue during the day or night. So in palpating the anterior digastric, you're below the area of the mandible. So, and you're in that tissue close to it. Now, when you're starting to palpate this, if you're not careful, you can get into the superficial master down in here and actually be pressing on the attachment of the master and not the posterior digastric. So kind of pay attention to where your hands are and the landmarks when you're looking at these things. But we'll go through that bilaterally as well and look at both sides to find out if there's anything in that area that should be tender or should be addressed when we're looking at things. And then going in here to the posterior, you can see trying to avoid touching too much into the angle of the mandible where you get into a different set of muscle groups there. And so we look at all these and then we wanna move on down even further because there are muscles in the head neck region that are interconnected with this. And this is one of the main ones is sternocleomastoid muscle. It originates down at the clavicle and the sternum area and inserts behind the ear and the mastoid process. It's involved in rotating your head and shrugging your shoulders. Now, when people clench heavily, I find, especially at night during the days, this will get pretty tender. And I have a lot of people say, yeah, I'm having a lot of neck problems. I've been to the chiropractor, but they're pointing to other things. And so I'm looking at that muscle as well because that should not be real tender through here. And granted, they could have some head and neck injuries, and that would be something a little bit different. But generally, on a day-to-day basis, this muscle should not be one that's uncomfortable. Poor posture can create some of this, or some of the other neck muscles we're gonna talk about, especially so many people on the phone and computers all day long, that can contribute to this as well. But also, the occlusion and clenching, bruxism, different things they do, parafunctional habits can create a lot of problems with this as well. So I'll take the fingers. I like, again, being behind the patient and run up the sternocleomastoid, you know, about a pound or two. You don't need quite as much pressure probably in this area either. And just run up through here. And sometimes they'll say, oh, oh, that actually feels better doing that. It's been so tight. And so I wanna document right or left, one, two, or three, if it is. And then from there, I'm gonna move on up to the attachment, which is really where you'll find a lot of discomfort. You know, right behind the ear and the mastoid process, kind of generally where I'm pointing here and palpate in that area. And again, a lot of times, and this is one muscle that doesn't necessarily have to be bilaterally on both sides. You can have one side that is, one side that's not, but I wanna document that. I find a heavy correlation between people that are having some bruxism or some other temporomandibular joint disorders that have a lot of neck problems. It can be intertwined with that reason. Because I have a lot of patients, after you get all that solved, they'll talk about how much better their neck is. Assuming, again, when you're doing these things, you need to be asking questions about the neck as well, which we'll talk about in a couple more slides here. Also, part of this is trapezius. And trapezius, and we'll talk about the spleen, the scapulatus, and they kind of overlap a little bit, but they run up and attach in the back of the neck. And again, they assist in tilting and rotating the head, and these can get pretty tender. So I'm moving from here back into the back part of the neck, as you can see here, I'm looking at the back part of the neck here between where the trapezius is attached, and then going in right into the spleen, the scapulatus, which is pretty much in the same general overlapping area. They do overlap a little bit here. And again, this muscle is responsible for some flexion, lateral rotation of the head, and extending the neck. And these muscles also can get pretty tender, especially with heavy night clenching, more so than anything else. But, and again, I'm assuming there's no head and neck trauma. There are a lot of people, including myself, that have fusion, and I've got some neck problems that are unrelated to my joint or my face as well. But ask those questions, find those things out here. So when we look at the muscles here, I wanna look, I wanna ask questions. Is there discomfort, unilateral, bilateral? Which area is that in? Was the patient aware of this? There's so many times they'll say, you know, I've never had any problems. I didn't know it was, I thought it's always supposed to be that way. Then I, you know, I'm asking, is there a question of, you know, night or day clenching, ruxism? And you can look at their teeth. A lot of times they'll deny that, but their teeth are worn flat. So you know there is. Sometimes they'll give a hint. They'll say, yeah, my sleeping partner says they hear me grinding my teeth all night long. Look at the canines. If they're doing the lateral movements, they're gonna be a little bit flat. Is there a history of temporal cervical headaches? If there is, how often? And I always ask questions generally with chewing food. And there's two ways, two things I'm looking for. Do you have difficult and chewing food? Like if it's real painful, I may be looking, if I eat some almonds or some nuts and it really hurts, thinking maybe joint could be muscle too, but also muscle fatigue. I'll have people, I'll say sometimes, if you're eating a steak or something chewy, do you have to put your fork down and rest for a minute because your jaws are so tired? And you'd be surprised. People will say that a lot. Yes, how did you know? And I'm like, well, just looking, all these are so sore. You're literally fatigued to that point. So that tells me there's something else going on there that we need to be aware of in our examination. So moving from the muscles, let's go over for a moment and look at the joint here. And again, you can have intertwine of both joint and muscle pain. A lot of times you have one or the other. A lot of times you'll have a lot of muscle problems and very little joint problems. And sometimes they're overlapping joint and muscle. So looking at this, and again, we're gonna show some photos in a minute here. I'm looking for landmarks to palpate. And so the tragus, part of the ear here, which I'll show in just a minute, we're gonna be palpating the posterior joint space. And on that, about a pound of pressure. I would not use two pounds. So you're gonna lighten up a little bit on that. Have the patient slowly, and I have to go through this many times with them. I'll say slowly open and close. Because if you say open and close, it's like snap, snap. I can't see anything that quickly. So I want them to slowly open, the maximum opening. I tell them, I said, don't hurt yourself. If it goes any further where it's gonna start hurting, let me know and stop there. Some people are so afraid, or they're so positioned to know when to stop because they know the pain's gonna begin. I wanna know where that point is. I'm not there to create pain, but I'm there to know what their limits are. So I look for tenderness and the posterior capsule space here. I look for deviations and flexions. We're gonna talk about that in a minute. The mandible move right or left, or we'll talk a little bit more looking at range of motion. Now that millimeter gauge I had a few slides back, we're gonna be measuring some things. And I tell the patient before I start this exam, I am gonna be measuring your range of motion. I'll demonstrate, I'm gonna be having you open till they know what you're doing before you get there. I'll tell them I'm gonna be doing lateral movements, left and right movements. And I'm looking for sounds, sounds that I can palpate or hear, or sounds that the patient may notice that maybe I cannot notice. And I'll ask them. And sometimes you have to interchange words. I can say your jaw click, and they'll go, no, it pops. So I always use clicking, popping, or do you have some crunchy, I don't say crepitus, most of the time they don't know what that is, but I'll say kind of a crunchiness. And they'll always light up and go, yeah, it's crunchy over here. So kind of ask those questions. And let's go through this, and we'll go into a little bit more detail here. So I think the first thing to look at is the posterior temporal joint space, temporal mandibular joint space here. And you can see, I've kind of circled where the tragus is, and then we're going to go into the posterior joint space here. And you can see the drawing, the anatomical drawing to the right of the screen here. So when they start this motion, again, make it slow. Technically, sometimes I have to repeat it. They still go too fast for me. I want a slow motion. As they open, your finger will fall into that posterior capsule or joint space area here. And so you'll feel that finger drop in there. You'll know you're in the right space. So have them open, have your finger there, about one pound of pressure, and then see kind of where they are. I'm not measuring the range of motion yet. I'm looking more for noises, sound, tenderness, and things of that nature. So I'll repeat that on both sides. I may have to repeat it several times, but I'm looking at a lot of different things. I like, again, standing behind the patient. Some clinicians like standing in front of the patients and watching them do this. It's just more comfortable for me to be behind, looking at the way the mandible is deflecting or deviating, if it's doing that. And I can kind of palpate at the same time. Now, the lateral pole, a condyle, is just right in front of that. That's pretty easy. I put my cotton tip applicator where that is. Just move your finger out of the posterior capsule, slightly forward, and you'll be on the lateral pole as they open and close. I find the posterior capsule or posterior space is more tender in most people than the lateral pole is. Now, some people, it is both. It doesn't take but a second, so I want to palpate both of those and make sure that I can document. Again, someone is documenting this as I'm going through this. We have a computer and we're just putting all this in. My assistant is while I'm going through each one of these steps here. So, when we're looking at this, we're looking at the posterior joint space. Lateral poles, painful and CO. In other words, I'm just touching before they open. Is it tender like this? Does it hurt when the range of motion start? Ask them, is there a history of some popping, locking, opening, closing? Some will remember, some will not. Some will be definitely knew they had some issues years ago but they'd forgotten about it. And ask them, is there a history? Can you go back and think about? Yeah, it used to pop 20 years ago. It quit. It went away is what they think, which is not necessarily true, but I want them to describe to them what kind of noise they hear. Because again, they describe it differently than what I'm trying to say in the terms clicking or popping. And I also want to look at head and neck injury. And the reason that is important is we see a lot of people come in, they'll say, well, and again, I'm never point blame to anybody. I'm just trying to get a history. But if they say, yeah, I had a car wreck. My head hit the windshield. Well, that's a good hint. You probably got some joint damage maybe from that. It's not important that I have to know that there's head and neck injury or they intubated in a surgery for a long period of time. Sometimes if you have a disc that's already strained, you do that. They'll wake up out of surgery and say, I can't open very wide. Wisdom teeth, extraction can do it. A lot of different things. It's not the end of the world if I don't have that information. It just helps me connect with my questionnaire if they do. So I'm looking at those kinds of things and trying to find that if I can. So let's go through these movements. So I think the best way for me, what's simple, is there's little marking sticks. You may have used them years ago when you're marking midlines for dentures. I like to sometimes have them bite into CO, put a little line, they're dental midlines, where their teeth line up. And if they don't line up, that's okay too. I just want to know where that midline is. So in this particular photo, they're pretty close to lining up here. And so when they start opening and closing, then I can tell even better. Sometimes there's a deviation or deflection on this. And we're going to, again, go into this in a little bit more detail in just a minute here. So what I'm trying to visualize here, and let's just go, you know, Weston and Erickson put this out years and years ago. You can get it on YouTube under the joint or best way to look at that. And you can look at this if you need to, joints, what I was trying to say, the joint, Y-O-N-T, not joint. So let's look at this for a minute. So now you have a disc. In this particular case, this disc is right here. Okay, it should be up here, but it's not. So as this person opens, you're going to be palpating and you're going to notice this thing is going to probably, if they have a history of clicking, it's going to probably click here. So let's kind of go through this. As you see this starting to move, the disc pops into place, you hear a click or a fill, and they close, it goes back out of place. They open again, and it's pretty consistent. I tried to measure roughly where that pop is, and it's not important that you know exactly. Is it doing this click, like at the first 20 to 30 millimeters, or is it doing it 40 millimeters? It's doing it when it's really open. So I'm just trying to look. Patients are a little bit confused about this. They think when it pops, it's going out of place. I have to kind of explain, I've got little models and things that I can kind of show them and say, no, actually it's going into place. It's out of place now. And so the problem with being off the disc, if there is a problem, and some people there's not, is if there's a lot of heavy clenching or things, you'll get a lot more pain because you're in a, out of that avascular area into a vascular area with a lot of innervation, so it can be quite tender. So we look at that. So this was a reducing disc dislocation we just looked at here. So before we go to a non-reducing, just look at this slide, and this will tell you a little bit. The one we just looked at, you heard a click or could see the click there, and that's reducing disc dislocation. It would be more of that V. You're going to open, capture the disc, and your midlines are most of the time will line back up. And so, and it's very repeatable, and it'll deviate to the side that's affected. So if it's the right side, you're going to deviate to the right and come back to the midline. So looking at the next one in a minute here, we're going to be looking at deflection. Now deflection is just a constant movement, right or left side, depending on which side is affected. There's not a click. You don't usually hear, you may hear some crepitus, but there's not going to be a click or pop. And it'll be a little bit different. So let's look here. You see where the disc is here as we start this video. It's down in this area right here. And you notice as they open, it stays in this area here. And they go to close, it stays, there it is, folded over right there. And so they open again. Again, no noise, no popping. Again, there could be some light crepitus. You're not going to hear that as much as you would a click in that situation like that. So this motion here, again, when we go through this, we're documenting. And if that is on the right side, I'll say right non-reducing distance location. And when I get through with the exam, I'm going to sit down and explain all this in great detail. I will ask questions. So if someone has a non-reducing disc or a reducing disc, on that side, I'm going to ask a lot more questions about tenderness. Did it used to lock and then quit locking or it used to hang up? And maybe now they say, no, it's better. It went away. And I know actuality, it did not go away. It's just pushed down further. So, excuse me. So sometimes we look at this, we can get a better idea where we're going, what we're trying to do. Now, if a patient comes in with a complaint that the disc is popping, that's another whole situation that's a little bit, not for this talk today that we'd have to dive into, but I'm wanting to document this. If I'm doing restorative work, yes, you've already got a non-reducing disc displacement right side. Maybe there's no pain, but I've got it documented. It's there. So if you do some restorative work, implants, sleep appliance, it's still going to be a non-reducing disc dislocation. Now, looking at chronic non-reducing disc dislocations. So a good hint, typically, if somebody can open 40 millimeters or more, we'll correct all this in a minute here, they usually, they got a pretty healthy range of motion. Most non-reducing disc dislocations, generally, and not 100%, are about 35 to 36, seven millimeters, maybe 34, mid 30s is where they are. Sometimes people will call on the phone and they'll say, oh my gosh, my jaw is locked or something's happened. I can't open. A quick way patients, and I have to be careful, they get obsessed with this. Can you stack three fingers? Usually that's close to upper 30s or 40 millimeters, or is it only two fingers? If people call on the phone, we get a lot of TMD patients and they'll say, I can't open wide. I ask, my team member will ask on the phone, can you stack two fingers or three fingers? If it's two fingers, I'm pretty much assuming there's already a non-reducing disc. I'm not diagnosing on the phone, but I'm getting something in my head I can think about here. So if it is non-reducing, try to get a little bit of history. When did it happen? Sometimes people say, yes, it was years ago. Some people never have any reconnection of that at all. And I always ask other questions at patients. When I'm looking, let's say I had a non-reducing disc dislocation and the patient wasn't aware of it and they opened 36 millimeters. So I'll ask questions like, if you go down to the local sub shop, do you have to mash the sandwich down to take a bite out of it? Or do you pinch your sandwiches? And most of these people will say, yes, I've been doing that for years. If they do, I ask how long they've been doing that for. Some people will say, well, no, I don't do that. But my hygiene is still, I get my teeth cleaned, says I have a real small mouth. So that's always another little hint is because not the mouth is that small, they just can't open that far. So those are some hints you can look at as well. Now there's some, if it goes on long enough, they get more into the crepitus wearing down. This can actually have some condylar change. Looking at here, you can tell there's not a lot of tissue there and you get a very, very thin amount. You'll actually get some wear of the condyle and even a little bit on the eminence there, you'll see changes radiographically after a few years of this. This is more of a crunchy, crackly feel, they'll say. And sometimes I can palpate and hear that, sometimes I cannot. Some of these people can open above 40 millimeters. All that tells me is that they have worn down or pushed that disc out of the way, they stretched the ligaments out. Now you'll still know that there is an affected side because they're going to deflect to that side. But some of these have no pain. We'll talk about radiographic findings in a minute. On those, I may be looking going, wow, that right side is really worn down. Go in there and everything's fine. I can open big. But again, there's usually some deflection. There's some hints that something is there with that. So looking, the next thing we're going to do, we've evaluated the muscles of the head and neck area. We've looked at the joint and now we're going to look at the actual range of motion in a physical way. So this little millimeter guide that I use here, they're disposable. This particular measurement, I say, go ahead and open to where you comfortably can open without any pain. And because again, some of these people I see are in so much pain, I'm not here to create a lot of pain, just to prove a point you can open two millimeters further. So this is about 30 millimeters that's going to send up a lot of red flags if I see them in the office. If that's the case most of those will have some discomfort I can't say a hundred percent but most of them will. So I'm looking at that a typical normal range should be 40 to 55 millimeters depending on the individual. So if you get people over 60 then you're getting a little bit more hypermobility in the joint. You don't see that very often. I see this quite often especially if it's under 30 most of these are in quite a bit of acute pain. So measure that and I'll ask them again. So that's another place you can ask about the sandwiches. If they're open 30 millimeters they're not eating a big Subway sandwich or eating something or mashing it down smaller. So again another another chance to just look and ask questions here. So I'm standing behind the patient. You can do this in front of the patient. So I have them go to CO and I'm saying open about a half-inch not very far just enough to uncouple the teeth. Move your jaw I'm saying to your left as far as you can go. I'm measuring I got the midlines lined up originally. This particular person is moving to the left side about 11 millimeters. Then I say okay relax your jaw. I don't like for me to go left to right real fast because I'm afraid if there is some joint laxity there there could be something I could pop or do something. So I said just relax your jaw. Okay now move to the right. I think it's kind of funny some of these patients say now which jaw am I moving the upper or the lower. Maybe that's a tendency thing I don't know. But anyway I get asked that awful lot. So we're looking at this here and I'm looking for something that's 8 to 10 millimeters is being normal. Sometimes you'll have joints that are affected and moving either laterally or contralaterally to that. It'll be kind of tender so or it's just restrictive. Most time it's pretty tender as well. So that's another measurement we're documenting. Now looking at again range of motion you got to take into account the over jet. If you look on the left side of the screen this person has between two and not quite three millimeters of over jet. So I got to add that to the range of motion. Then you have them protrude out and you look and you take the measurement you add those two together. We'd like to see people move about 10 millimeters if they can. Again a lot of times people are very uncomfortable they can't do that. Again red flags to be asking more questions of how long it's been like that or notice when they move forward or backwards or they're clicking. Is there a pop there? Some do that as well. So we want to ask a lot of questions. Take these measurements. You can also use a paradigm probe if you don't want to use a little millimeter ruler like I was using. This just shows trying to measure the over jet and the overbite. Looking at that and you can do this as well with just a paradigm probe if you feel like that's easier for you to do. So now we looked at muscles and things. We're going to look at motions. We're looking at now a summary of what we've done with the jaw movements. Is it under 40 millimeters? Again I'm thinking is there under 40? Is there pain associated with it being under 40? Is there pain on palpation? Is there deviation or deflection in that? Most of the time there is some. Unless they're really acute. Now if they're very acute they're just going to rotate in the joint. They're not going to come out enough to deflect or deviate. But look at that. Are there noise? Radiographic evidence. We're going to talk about that in just a minute. History of pain or injuries can also add to that as well. Now while we're on all these subjects we've got one more area here that we need to look at before we get to the radiographical findings and that's cervical range of motion. A lot of what we do in dentistry we don't think about. When we restore, I used to do a lot of full mouth reconstructions. We restore occlusion completely. If you put a sleep appliance in, you'd put the implants over an implanted supported denture. You're changing that vertical. A lot of times that can affect the upper neck if you especially if you do too much. So I quickly just have the patient go. We'll go through these things here. I have them just talk about neutral. If they can extend their head back. Flexion going forward. You know right and left flexion. Some people can do this and then rotation right and left. Now you'll see a variety of things depending on the history of the patient. So those are kind of important. I still want to document those. You have a few people that you can again 40 years I made a lot of mistakes over the years. So you open zones vertical too much and they may start saying this is starting to hurt around my jaws and my upper neck. So you want to have this documented as you are going through your examination. These are all this seems like this is a lot takes a long period of time. You can do most of stuff in 10 minutes or less on some of these things here. So cervical movements neutral extension and flexion. This lady now I knew before I took these photographs she was fused from C2 to C7. So she is fused all the way from the top to the bottom. So I expect her movements to be a lot more limited than some healthy person that can literally move 90 degrees right or left or extend completely up and the flexion. Hers is going to be a little bit more limited and especially her cervical flexion. You see on the right side she can barely even move to her right as well as left a little bit better but still not know where it needs to be. But because we have a history we know she's fused and most of these people do have some residual long-term discomfort. I'm not I'm just tell people this is already here. I may or may not be able to change this but I'm not gonna make it any worse and whatever I'm trying to do will stabilize it. Sometimes we can make it better if the discomfort is being caused by the mandible and some of these other muscles. If there's already surgery from trauma then we're not going to probably be able to do a lot to make that a whole lot better. Sometimes you can. Notice her rotation right and left. Pretty good on her right. You'd like that to be about 90 degrees. On her left a little bit more limited and you'll find this very common in people that have been fused. Now you have to ask them. I look for scars while I'm just face-to-face talking to patient. I'm scanning the neckline to see if there's a scar from a fusion. Sometimes you can notice it. If there is, I'll ask. Sometimes I'll just you can see it if you take a Panarex or combing sometimes it'll show up and the hardware will show up in that but please ask those questions. So we look at abnormal cervical movements. So you know is it you know tenderness found on palpation when you're moving extension flexion look at those things and again I mentioned history of cervical surgeries. Some people don't know my neck doesn't bother me too much. I go to the chiropractor every week. Well I'm gonna be asking why do you go to the chiropractor every week or I get needling twice a month or I get physical therapy so my neck doesn't hurt. Well that tells me something's going on there to have to go to that treatment. Some of them are taking medication. Some of us prescribe. Some of them on pain management. Some of them just take not take Advil every day and to me that's still something you need to explore. Why? Are they taking these things? And this will show up a lot of times in this sternocleomastoid muscles and the splenus capitis these areas here you can palpate you'll find some some issues with that. It can be from it's either I call descending pain that's created up here and it's going down the neck or you may have in this case you guys somebody has some surgery that's ascending pain that starts here and ascends up into the neck area. So try to look at those things and try to be definitive when you're looking at these things. So we got another little area here and again this is just more information more hints of things to look at radiographically. So there's a lot of different ways whatever you have whatever tools you have. Panoramics been around obviously for years and a lot of general practices have these. Comb beam technology is coming down in price. Some of the people have these. MRIs we don't use a lot unless there's specific treatment which I will talk about. It's very helpful to tool you can get a lot of information out of an MRI. So let's look here. So I'm looking when I'm doing a panoramic or comb beam image I'm looking at several things. I'm looking at the condor head. It's a right and left side symmetrical. Sometimes one side may be worn down. Let's say you got a non-reducing distance location in which you have a lot of inflammation and this condyle may be a little bit more flat than the left one if there's wear there. Are the condyles where are they placed in the fossil? You know if they're very distantly placed almost to the ear canal I can almost assume before I walk in the room there's going to be a reducing or dis-displacement whether it's reducing or non-reducing. I'm looking for osseous pathology. Then also when you're in the mouth you can look for toroid. That's a huge thing. I see a lot of wear on the condyles. Huge lingual toroid. Fractured teeth obviously restorations parallel pathology. All those things you can look at and so let's look at a few of these things here for a minute. This is a panoramic view here and you look good complement of teeth but you can see there's a little bit of pathology up near the condor head right below it. I should say not at it but right below it. Why is that there? Is that something that causes some discomfort? If it's not and it's suspicious of any way obviously get that referred out for pathology or get at least get the the panoramic or comb beam read by a radiologist to make sure but document that or let patients know there's something suspicious there. So when you look at this particular panoramic view look at how flat these condor heads are. Usually there's very limited joint space there just because the condyle is forward from there. You can't see the condyle on here. You've worn that tissue down to a point they're moving back and forth all day or all night long and that condor head literally gets flat. So that's another hint that makes me look before I even go in the room if I'm looking at the radiographical images first. Also I'm looking quickly because again in my practice I don't have dental hygiene. Now if you got a hygiene in your practice you should be looking for all the periodontal problems to begin with. Sometimes they'll come in and you see right here there's a little bit of bone loss between the two centrals in the front. If you're doing some treatment whether it's restorative maybe if you're a specialist or you're doing implants or other things look for things like this. Don't assume that where they came from they've already treated and taking care of that. Sometimes we see patients for TMD that hasn't been to a dentist in 10 years so they really have to get them back to get their teeth cleaned and all those things done. So getting over to Conebeam now we look at this and I you see I've got circles around the condor area there and so there's pathologies remodeling of the condyle. But you can also look up especially on this right side look at how little space there is there a little bit more here there's less space there. So I I'm also looking again a lot of times this is a minimally a non-reducing disc there could be still a little bit of crepitus there but that's a good hint. I see a lot of condyles like this in my practice. Also noticing where the condylar head is. So looking and we'll talk about descriptions and definitions in just a second. That condylar head is in the distal half of this fossa is you know should be more up this direction it's way back here. So if I'm looking at this image and I haven't even seen the patient yet I want to assume there's some disc displacement of some type there. It's just very unusual to have a healthy disc and open and closing no deflection or deviation that far back in the fossa. So that's a very good hint to look at and pathology. You see there's some bony area up here on this one and again and some people I call this beaking that's just chondro pathology bony pathology. So much stress and pull on this that literally bone is starting to beak out or like we call a bird's beak is a kind of a layman's way to look at that if you're going to. So look at those things as well and again a lot of this you'll see. Now let's go to MRIs for a minute. So I don't routinely have people to make them have an MRI depending on what we're doing. If we're having to do a lot of extensive TMD treatment we know the disc is out of place. An MRI is the only way you're gonna know exactly where that disc is. Combine you will not be able to see the disc. You can see the location of the condyle but you can't see where the disc is. So if you really need to know this then you may want to talk about an MRI imaging. So you can there's several ways to do this. You can have their internal medicine. A lot of times dentists we medically if your patient is expecting medical reimbursement this dentist can't write a prescription. Now we can send people for MRIs and they'll take the MRI if they're not doing insurance met you know a dentist again doing this. So sometimes we'll even talk to some of the facilities if we're doing multiple MRIs on people through time and say if they're if they have a high deductible we can get a kind of a cash discount to do an MRI. I'm a little bit selective obviously if I'm trying to reposition this condyle if I can if it's acute I'm trying to do an injection a lot of different things you might need an MRI. Typically speaking I don't routinely send everybody for an MRI depending on again what we're doing in the office at that time. Just be aware they can be done if they are you want a CO position a maximum opening so you can look and kind of see where the articular disc is in those positions. So also keep in mind where our centric relation should be. 1987 before then this was all over the board I have been practicing for many years and I remember when it used to be the utmost posterior you'd push the jaw up and back. I went to classes on that and so now is more in the thinnest part of the disc area in the amp upper anterior superior part and this was been pretty consistent that area since 1987. That's with a jaw and the teeth and intercuspations where it should be. So when we look there's other ways again I just loosely use this also Michael Gebb had the Gelb's condylar position. What he did is took the chondrofossa and made a grid one two three four five six seven. He's saying that the four seven position is the healthy position the joint should be in. You need to know that or remember that maybe not it's just another thought if you're looking at radiographs quite a bit which I do of where that position is. If this isn't a five seven or two five position then I'm gonna be thinking there's a disc that's out of place. So that's something we want to look at and whether you see our and I use both look course I'm looking in intraorally as well not just a radiograph here but that's another way that some people refer to the joint position chondroi. So we're looking for radiographically is there remodeling of the head the beaking the different things we see in there the flattening of the condyle. Is there location in the you know the glenoid fossa which position is it in or is it distantly placed. There's asymmetry sometime you'll have one condyle that'll be perfectly looks great and one that's not. Sometimes that can be a skeletal issue or it can be a dental issue or just trauma through years because so it can be either one. Note those things and then what I do at this point I've gone through all these things I know it's taken a little bit of time here but in a patient this doesn't take that much time. We ask questions we get a lot of pre questions to the questionnaires and different things we're going through the muscles the joints I'm asking questions trying to understand where they are right now where is their joint as far as comfort pain range of motion is there anything I'm going to be doing to in fact to affect that. So we look at these things and try to try to get this done. So in conclusion of all these things here what I'm trying to do is make the patient aware informed consent and a confounder which would basically explain I say you've got a non-reducing disc right side now I go into detail with a patient. We can communicate that way pretty easily a patient won't have any idea what you're talking about. So I'll just say your disc is down I'll kind of have a little diagram and I kind of described your disc is non-reducing you don't have any pain what we're going to do X Y or Z will not be affected by this but I just want to make you aware you have a non-reducing disc. If I'm doing something maybe opening them up if it's a full mouth reconstruction or in this case a sleep appliance I may want to inform them this disc could start reducing it may start clicking just let them know or if there's they're not aware of anything there's a lot of tenderness I may just say you know you it looks like you have a history of some bruxism here let them know what's there they sign it and you have somebody also a team member or somebody witnesses and again this is meant to be just informative let patients know what's there so you know before you starting treatment the patient knows before you starting treatment and everybody's on the same page so you can move forward whether you're actually treating any TMD issue or just making the patient aware of what's there and what's going on. I hope this has been helpful going through this and this would be something that can be implemented in your practice whether you're getting general dental or what type of practice you have I think this is very critical to go through these things and I want to thank you for the time you spent here today. Thank you.

temporomandibular joint evaluation

TMJ importance in dental practice

patient symptoms documentation

joint movements evaluation

range of motion measurement

radiographic imaging for TMJ assessment

patient communication of findings

informed consent in treatment planning

potential need for TMJ MRI