Diagnostic Terms and Clinical Criteria for Temporomandibular Disorders

Clinical Criteria for Temporomandibular Disorders

History: Questions to Ask when Evaluating a Patient for Mandibular Dysfunction

Do you have pain in the face, in front of the ear and temple areas? Do you get headaches, earaches, neckache, or cheek pain? When is pain at its worst (morning [on awakening] or as day progresses [toward evening])? Do you experience pain when using the jaw (opening wide, yawning, chewing, speaking, or swallowing)? Do you experience pain in the teeth? Do you experience joint noises when moving your jaw or when chewing (clicking, popping, or crepitus)? Does your jaw ever lock or get stuck (locking in the open position or locking in the closed position)? Does your jaw motion feel restricted? Have you had an abrupt change in the way your teeth meet together? Does your bite feel “off” or uncomfortable? Have you had any jaw injuries? Have you had treatment for the jaw symptoms? If so, what was the effect? Do you have any other muscle, bone, or joint problem such as arthritis or fibromyalgia? Do you have pain in any other body sites?

Anteriorly displaced and deformed, degenerated disc  and irregular cortical outline with osteophytosis and sclerosis of condyle.

Diagnostic Classification of Temporomandibular Disorders
Diagnostic Category	Diagnoses
Cranial bones (including the mandible)	Congenital and developmental disorders: aplasia, hypoplasia, hyperplasia, dysplasia (eg, 1st and 2nd branchial arch anomalies, hemifacial microsomia, Pierre Robin syndrome, Treacher Collinssyndrome, condylar hyperplasia, prognathism, fibrous dysplasia) Acquired disorders (neoplasia, fracture)
Temporomandibular joint disorders	Deviation in form Disk displacement (with reduction; without reduction) Dislocation Inflammatory conditions (synovitis, capsulitis) Arthritides (osteoarthritis, osteoarthrosis polyarthritides) Ankylosis (fibrous, bony) Neoplasia
Masticatory muscle disorders	Myofascial pain Myositis Spasm Protective splinting Contracture

Advanced osteoarthritis and anterior disc displacement, with joint effusion 

Classification for Diagnosing Temporomandibular Disorders
Muscle and facial disorders	Myalgia; muscle contracture; splinting; hypertrophy; spasm; dyskinesia; forceful jaw closure habit; myositis (bruxism)
TMJ disorders	Disk condyle incoordination; osteoarthritis; disk condyle restriction; inflammatory polyarthritis; open dislocation; traumatic articular disease; arthralgia
Disorder of mandibular mobility	Ankylosis; adhesions (intracapsular); fibrosis of muscular tissue; coronoid elongation-hypermobility of TMJ
Disorders of maxillomandibular growth	Masticatory-muscle hypertrophy/atrophy; neoplasia (muscle, maxillomandibular or condylar); maxillomandibular or condylar hypoplasia/ hyperplasia

 Rheumatoid arthritis. A MRI shows completely destroyed disc, replaced by fibrous or vascular pannus and cortical punched-out erosion (arrow) with sclerosis in condyle.

Diagnostic Terms and Clinical Criteria for Temporomandibular Disorders
Diagnostic Terms	Clinical Criteria
Deviation in form (painless mechanical dysfunction or altered function due to irregularities or aberrations in form of the intracapsular soft and hard articular tissues)	Complaint of faulty or compromised joint mechanics. Reproducible joint noise, usually at the same position during opening and closing Radiographic evidence of structural bony abnormality or loss of normal shape
Disk displacement with reduction (abrupt alteration or interference of the disk-condyle structural relation during mandibular translation with mouth opening and closing; from a closed-mouth position, the “temporarily” misaligned disk reduces or improves its structural relation with the condyle when mandibular translation occurs with mouth opening, which  produces joint noise described as clicking or popping)	Pain (when present) is precipitated by joint movement. Reproducible joint noise, usually at variable positions during opening and closing mandibular movements Soft-tissue imaging reveals displaced disk that improves its position during jaw opening. Clinical findings that may support the diagnosis:     pain (when present) precipitated by joint movement; deviation during movement coinciding with a click; no restriction in mandibular  movement (episodic and momentary catching of smooth jaw movements during mouth opening [< 35 mm] that self-reduces with voluntary mandibular repositioning)
Disk displacement without reduction (altered or misaligned disk-condyle structural relation that is maintained during mandibular translation)	Pain precipitated by function Marked limited mandibular opening Straight-line deviation to the affected side on opening Marked limited laterotrusion to the contralateral side Soft-tissue imaging reveals displaced disk without reduction. Clinical findings that may support the diagnosis: pain precipitated by forced mouth opening; history of clicking that ceases with the locking; pain with palpation of the affected joint; ipsilateral hyperocclusion
Synovitis or capsulitis (inflammation of the synovial lining or capsular lining)	Localized pain at rest exacerbated by function, especially with superior and posterior joint loading Limited range of motion secondary to pain T2-weighted MRI may show joint fluid.
Osteoarthrosis (degenerative noninflammatory condition of the joint, characterized by structural changes of joint surfaces secondary to excessive straining of the remodeling mechanism)	Crepitus Limited range of motion causes deviation to the affected side on opening. Radiographic evidence of structural bony change (subchondral sclerosis, osteophyte formation) and joint-space narrowing
Osteoarthritis (degenerative condition accompanied by secondary inflammation [synovitis] of the TMJ)	Same as for osteoarthritis, plus crepitus or multiple joint noises, pain with function due to  inflammation, and point tenderness on palpation
Myofascial pain (regional dull aching pain and presence of localized tender spots [trigger points] in muscle, tendon, or fascia that reproduce pain when palpated and may produce a characteristic pattern of regional referred pain and/or autonomic symptoms on provocation)	Regional pain, usually dull Localized tenderness in firm bands of muscle and/or fascia Reduction in pain with local muscle anesthetic injection or vapocoolant spray and stretch of muscle trigger points
Myositis, delayed onset (painful condition due to intermittent overuse that results in interstitial inflammation)	Increased pain with mandibular movement Onset following prolonged or unaccustomed use (up to 48 hours afterward)
Myositis, generalized (constant, acutely painful, and generalized inflammation and swelling, usually of the entire muscle)	Pain usually acute in localized area Localized tenderness over entire region of the muscle Increased pain with mandibular movement Moderately to severely limited range of motion, due to pain and swelling Onset following injury or infection
Protective muscle splinting (restricted or guarded mandibular movement due to cocontraction of muscles as a means of avoiding pain caused by movement of the parts)	Severe pain with function but not at rest Marked limited range of motion without significant increase on passive stretch
Contracture (chronic resistance of a muscle to passive stretch, as a result of fibrosis of the supporting tendon, ligaments, or muscle fibers themselves)	Limited range of motion Unyielding firmness on passive stretch History of trauma or infection

Condylar hypoplasia and facial asymmetry

Definitions and Clinial Criteria for Temporomandibular Disorders
Definitions	Clinical Criteria
Myofascial pain (pain of muscle origin, including complaint of pain associated with localized areas of tenderness to palpation in muscle)	Report of pain or ache in jaw, temples, face, preauricular area, or inside ear at rest or during function, and pain on palpation in three or more muscle sites
Myofascial pain with limited opening	Myofascial pain, pain-free unassisted mandibular opening of < 40 mm, and a maximum assisted opening of ≥ 5 mm greater than the pain-free unassisted opening
Disk displacement with reduction (disk is displaced from its position between the condyle and eminence to an anterior and medial or lateral position but is reduced in full opening usually resulting in a noise)	Click on both vertical opening and closing that occurs at a point at least 5 mm (interincisal opening) greater than on closing, is eliminated on protrusive opening, and is reproducible in two of three consecutive trials or click on opening or closing and click on lateral excursion or protrusion, reproducible in two of three consecutive trials
Disk displacement without reduction, with limited opening (disk is displaced from normal position between condyle and fossa to an anterior and medial or lateral position, associated with limited opening)	History of significant limitation of opening Maximum unassisted opening ≤ 35 mm, passive stretch increases opening by ≤ 4 mm, and  contralateral excursion < 7 mm and/or uncorrected deviation to the ipsilateral side on opening Absence of joint sounds or sounds that do not meet criteria for disk displacement with reduction
Disk displacement without reduction without limited opening (disk is displaced from its position between condyle and eminence to an anterior and medial or lateral position, not associated with limited opening)	History of significant limitation of mandibular opening Maximum unassisted opening > 35 mm, passive stretch increases opening by ≥ 5 mm over maximum unassisted opening, contralateral excursion ≥ 7 mm, and presence of joint sounds not meeting criteria for disk displacement with reduction
Arthralgia (pain and tenderness in joint capsule and/or synovial lining of the TMJ)	Pain in one or both joint sites and self-report of pain in region of joint Pain in joint during maximum opening (assisted or unassisted) Pain in joint during lateral excursion
Osteoarthritis of the TMJ (inflammatory condition within the joint, resulting from a degenerative condition of joint structures)	Arthralgia and coarse crepitus or imaging showing one or more of the following: erosion of normal cortical outlines, sclerosis of parts or all of condyle and articular eminence, flattening of joint surfaces, osteophyte formation
Osteoarthrosis of the TMJ (degenerative joint disorder in which joint form and structure are abnormal)	Absence of arthralgia Coarse crepitus or imaging showing one or more of the following: erosion of normal cortical outlines, sclerosis of parts or all of condyle and articular eminence, flattening of joint surfaces, osteophyte formation

A PPT Lecture note on TMJ