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OFP Mock Formative Q2 - TMJ Disc Displacement and Clicking

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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

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