Clinical features

The main symptoms of TMD pain are as follows.

• Site: TMJ and associated musculature, unilateral or bilateral

• Radiation: associated muscles, temple, neck

• Character: dull, aching, throbbing, sometimes sharp

• Severity: mild to moderate

• Duration: weeks to years

• Periodicity: continuous, can be intermittent or worse on waking or at the end of the day

• Provoking factors: jaw movement, eating, stress

• Relieving factors: jaw rest, tricyclic drugs

• Associated factors: limited mouth opening, TMJ parafunction, bruxism, anxiety, other pain sites

The effect of TMD pain on quality of life has been assessed in large population-based studies using the Graded Chronic Pain Scale [27]. This scale yields four grades: Grades 3 and 4 are associated with increasing high levels of psychosocial disability whereas Grades 1 and 2 relate to high pain intensity but relatively little daily living disability. In these studies 15-18% had Grade

3 disability and 3-6% Grade 4. These patients score high on depression, are high users of healthcare services and are resistant to change with treatment. Turp [2] showed that 66% of a group of 278 TMD patients referred to a tertiary center had widespread pain and these patients scored significantly higher on the Pain Disability Index and the Beck Depression Inventory.

Examination involves the application of pressure to a variety of specific anatomic sites (trigger points) to see if the muscles are tender. The range of movement of the mandible is then evaluated in vertical opening, protrusive and lateral positions. These ranges of movements are measured in three positions: when pain free, with unassisted maximal opening and assisted maximal opening. The distance is measured between the incisive edge of the upper central incisor and the lower mandibular incisor in millimeters and there is reasonable agreement in these measurements. Although joint sounds and crepitus are listened for, they are not highly diagnostic. Crepitus may indicate an arthrosis.

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