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OFP Mock Formative Q2 - TMJ Disc Displacement and Clicking_integrated

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Mock OSCE Question 2

L33 Temporomandibular disorders; Extracapsular disorders

Karen is a 35-year-old female who presents to your dental practice reporting a clicking sound in her right jaw joint that has been present for approximately 12 months. She describes intermittent right-sided jaw pain, particularly during chewing and when opening widely. She also reports occasional brief episodes in which her jaw momentarily “locks” on opening, but states that she is always able to free it herself with a small jaw movement. There is no significant restriction of mouth opening and she has no prior history of trauma to the jaw. On examination, maximum unassisted mouth opening is 42 mm with a reproducible click on the right side during both opening and closing. There is mild tenderness on palpation of the right masseter and right lateral pole of the condyle.

  1. What causes unilateral jaw clicking. (3 marks)
  2. Based solely on the information provided above, what are the possible diagnoses for this patient? (3 marks)
  3. Describe the key components of your clinical examination of this patient’s temporomandibular joints and masticatory muscles. (3 marks)
  4. List 3 investigations that may assist in the diagnosis and management of this patient. (3 marks)
  5. Outline the conservative management options available for this patient’s condition. (3 marks)
  6. Identify 3 findings or factors that would indicate a need for specialist referral. (3 marks)
  7. List 3 factors that may influence this patient’s prognosis. (3 marks)

First try answers

  • 1
    • High filling
    • unilateral condylar resorption
    • unilateral trauma
    • unilateral myalgia?
  • 2
    • Disk displacement with reduction with locking
    • Myalgia
    • ?
  • 3
    • Palpation of TMJ during opening and excursive/protrusive movements
    • Pressing on masticatory muscles to determine trigger points -?
  • 4
    • MRI
    • Ultrasound
  • 5
    • Jaw stretching excercises (opening to max 20 times , 5 times a day)?
    • NSAIDs
    • Accupuncture
  • 6
    • Pain
    • Constant locking
    • Deflection
  • 7
    • Frequency of locking
    • Severity of symptoms
    • If symptoms are progressing or reducing

Marking Key

Causes of unilateral:

  • Microtrauma (i.e. overactive muscles)
  • Macrotrauma (pucnh)
  • Motor vehicle incidents ( i.e. acceleration deceleration)

Possible Diagnoses for the patient

  • Arthralgia (e.g. capsulitis)
  • Myalgia
  • Disc displacement with reduction and intermittent locking
  • “Right TMJ disc displacement with reduction;right TMJ disc displacement with reduction with intermittent locking; right TMJ arthralgia. Accept any clinically consistent combination of these diagnoses based on the history and examination of findings provided.”

**Key Components of clinical examination of the patient’s temporomandibular joints and masticatory muscles **

  • visual inspection for facial asymmetry and mandibular deviation on opening; measurement of maximum unassisted and assisted mouth opening (in mm), lateral excursion and protrusion ; palpation of the TMJs (lateral pole and posterior attachement) and masticatory muscles (masseter , temporalis, medial and lateral pterygoid ) for tenderness; palpation or auscultation for joint sounds with characterisation of timing (opening click, closing click or crepitus)

**Key investigations

  • OPG as a baseline assessment of bony joint architecture; MRI of the TMJs to assess disc position, morphology, and the presence of joint effusion; CBCT where bony pathology, condylar resorption, or articular surface changes are suspected; serological investigations (e.g. ESR, CRP, rheumatoid factor, ANA) if systemic arthritis is a differential diagnosis

Conservative Patient Management Options

  • Patient education and reassurance;
  • Dietary modification
    • soft diet
    • avoidance of hard foods and wide opening
  • Parafunctional habit awareness and reversal (e.g. clenching, jaw bracing)
  • stabilisation splint therapy
  • directed jaw excercies and physiotherapy
  • NSAIDs for pain management

Need for specialist referral

  • Failure to respond to an adequate trial of conservative manangement
  • Progressive restirction of mouth opneing or worsening of symptoms
  • evidence of structural joint destruction or condylar resorption on imaging
  • suspected systemic arthritis requiring rehumatological assessment;
  • diagnostic uncertainty;
  • significant psychosocial impact or comorbid chornic pain conditions requiring multidisciplinary input

**Factors Influencing Patients Prognosis

  • Severity and chronicity of the disorder at presentation
  • Presence of psychosocial comorbidities including anxiety, depression, and pain catastrophizing; degree of structural change evident on imaging; patient adherence to self-management strategies; coexistence of other chronic overlapping pain conditions

Total: 21 marks

Audio Appendix

Additional Audio Content

The following sections from the lecture audio did not correspond to any heading in the main document.

Possible Diagnoses

Based on the clinical presentation of pain, intermittent locking, and muscle tenderness, the following diagnoses are suggested:

  • Local Myalgia: Muscle pain, specifically noted in the masseter.
  • Arthralgia: Joint pain (preferred over the more specific “capsulitis”).
  • Disc Displacement with Reduction: Indicated by the clicking and the ability of the patient to free the jaw when it locks.

Clinical Examination Components

To properly assess the TMJs and masticatory muscles, the following three components should be included:

  • Assessment of Jaw Function:
    • Measuring maximum mouth opening (assisted and unassisted).
    • Checking for asymmetry or deviations.
    • Measuring lateral excursive and protrusive movements.
  • Palpation: Palpating the TMJs and masticatory muscles to check for tenderness or radiating pain.
  • Auscultation: Listening to the joint to identify and characterize clicking sounds.

Investigations for Diagnosis and Management

The following investigations may assist in managing the patient:

  • Imaging:
    • MRI: Considered the “most ideal” for visualizing disc displacement.
    • OPG (Orthopantomogram): A standard dental investigation.
    • CBCT (Cone Beam Computed Tomography): Useful for looking at bony structures.
    • Ultrasound.
  • Serology: Blood tests may be indicated if systemic conditions like rheumatoid arthritis or mixed connective tissue disease are suspected.
  • Note: Imaging is often only necessary if the diagnosis is uncertain or if there is evidence of structural joint destruction.

Factors Influencing Prognosis

The following factors can affect the likely outcome for the patient:

  • Severity and Chronicity: How long the disorder has been present and its intensity.
  • Psychosocial Comorbidities: The patient’s mental and social health status.
  • Structural Changes: The degree of change visible on imaging.
  • Patient Compliance: Adherence to self-management strategies and exercises.
  • Central Sensitization: The presence of other chronic overlapping pain conditions.

Conservative Management Options

Conservative (non-surgical) management strategies include:

  • Patient Education and Reassurance: Explaining the condition to the patient.
  • Behavioral Modification: Awareness and reversal of parafunctional habits (e.g., bruxism).
  • Dietary Modification: Adopting a soft diet and avoiding pain-triggering foods.
  • Physical Therapy: Jaw exercises and physiotherapy.
  • Pharmacotherapy:
    • Pain management using NSAIDs (e.g., Ibuprofen 600mg three times a day).
    • Topical treatments like Diclofenac gel.
  • Stabilization Appliances: Use of oral appliances/splints.

Causes of Unilateral Jaw Clicking

The lecture identifies several factors that can lead to unilateral clicking in the jaw joint:

  • Micro-trauma: This includes habits such as bruxism.
  • Macro-trauma: Significant physical injuries such as a blow to the jaw, motor vehicle accidents, or acceleration-deceleration injuries.
  • Disc Displacement: Specifically, internal derangement of the joint.
  • Muscle Activity: Overactive muscles.
  • Idiopathic: The condition can sometimes occur with no apparent or obvious reason.
  • Note: The speaker explicitly states that a “high filling” is not a cause of this condition.

Indications for Specialist Referral

A patient should be referred to a specialist if the following factors are present:

  • Persistent Symptoms: Lack of improvement despite adequate trials of conservative management.
  • Progressive Limitation: Increasingly restricted mouth opening.
  • Structural Changes: Evidence of joint destruction or condylar resorption on imaging.
  • Systemic Involvement: Suspected systemic arthritis (e.g., rheumatoid arthritis).
  • Diagnostic Uncertainty: When the clinician is unsure of the underlying cause.
  • Psychosocial Impact: Significant impact on the patient’s life or presence of chronic pain (central sensitization).
  • Pathology: Suspicion of a tumor or mass in the jaw joint.

Case Study: 12-Month History of Right-Sided Jaw Clicking and Pain

  • Patient Presentation: A female patient presents with a clicking sound in her right jaw joint that has been present for approximately 12 months.
  • Symptoms:
    • Left-sided deviation.
    • Intermittent right-sided jaw pain, specifically when chewing or opening widely.
    • Occasional brief episodes where the jaw momentarily locks on opening, though the patient can free it with a small jaw movement.
    • No significant restriction of mouth opening.
    • No prior history of trauma to the jaw.
  • Clinical Examination Findings:
    • Maximum unassisted mouth opening is 22 mm.
    • Reproducible click on the right side during both opening and closing.
    • Mild tenderness on palpation of the right masseter muscle and the right lateral pole of the condyle.

Graph View