<h1>Oral Health Centre of Western Australia</h1> <h2>Form 29</h2> <h3>Use Patient Barcode Label</h3> <p>Given Name: ______</p> <p>Surname: ______</p> <p>DOB: ______</p> <p>TEMP: ______</p> <h2>Part 1 — Masticatory System Function/Dysfunction Survey</h2> <h3>Anamnestic Dysfunction Index, A. (Helkimo 1974)</h3> <table border="1"> <tr> <th rowspan="1">A, O</th> <td colspan="4">denotes complete absence of subjective symptoms of dysfunction of the masticatory system</td> </tr> <tr> <th rowspan="1">A, I</th> <td colspan="4">denotes mild symptoms such as temporomandibular joint sounds such as clicking and crepitation, feeling of stiffness or fatigue of the jaws</td> </tr> <tr> <th rowspan="1">A, II</th> <td colspan="4">denotes severe symptom of dysfunction. One or more of the following symptoms were reported in the anamnesis: difficulty in opening the mouth wide, locking, luxations, pain on movement, facial and jaw pain</td> </tr> <tr> <th rowspan="1">Date</th> <td colspan="1"></td> <td colspan="1"></td> <td colspan="1"></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> <td></td> </tr> </table> <h3>Clinical Dysfunction Index, D. Based on evaluation of five common symptoms</h3> <table border="1"> <tr> <th rowspan="3">A</th> <td>Symptom:</td> <td>Impaired range of movement/mobility index</td> </tr> <tr> <td>Criteria:</td> <td>Normal range of movement</td> <td>0</td> <td></td> <td></td> </tr> <tr> <td></td> <td>Slightly impaired mobility</td> <td>1</td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td>Severely impaired mobility</td> <td>5</td> <td></td> <td></td> </tr> <tr> <th rowspan="4">B</th> <td>Symptom:</td> <td>Impaired TM joint function</td> </tr> <tr> <td>Criteria:</td> <td>Smooth movement without TM joint sounds and deviation on opening or closing movements < 2mm</td> <td>0</td> <td></td> <td></td> </tr> <tr> <td></td> <td>TM joint sounds in one or both joints and/or deviation ≥ 2mm on opening or closing movements</td> <td>1</td> <td></td> <td></td> </tr> <tr> <td></td> <td>Locking and/or luxation of the TM joint</td> <td>5</td> <td></td> <td></td> </tr> <tr> <th rowspan="3">C</th> <td>Symptom:</td> <td>Muscle pain</td> </tr> <tr> <td>Criteria:</td> <td>No tenderness to palpation in masticatory muscles</td> <td>0</td> <td></td> <td></td> </tr> <tr> <td></td> <td>Tenderness or palpation in 1-3 palpation sites</td> <td>1</td> <td></td> <td></td> </tr> <tr> <td></td> <td>Tenderness to palpation in 4 or more palpation sites</td> <td>5</td> <td></td> <td></td> </tr> <tr> <th rowspan="3">D</th> <td>Symptom:</td> <td>Temporomandibular joint pain</td> </tr> <tr> <td>Criteria:</td> <td>No tenderness to palpation</td> <td>0</td> <td></td> <td></td> </tr> <tr> <td></td> <td>Tenderness to palpation laterally</td> <td>1</td> <td></td> <td></td> </tr> <tr> <td></td> <td>Tenderness to palpation posteriorly</td> <td>5</td> <td></td> <td></td> </tr> <tr> <th rowspan="3">E</th> <td>Symptom:</td> <td>Pain on movement of the mandible</td> </tr> <tr> <td>Criteria:</td> <td>No pain on movement</td> <td>0</td> <td></td> <td></td> </tr> <tr> <td></td> <td>Pain on 1 movement</td> <td>1</td> <td></td> <td></td> </tr> <tr> <td></td> <td>Pain on 2 or more movements</td> <td>5</td> <td></td> <td></td> </tr> <tr> <th rowspan="1">F</th> <td colspan="1">Sum A + B + C + D + E = dysfunction score (0-25 points)</td> </tr> <tr> <th rowspan="4">G</th> <td rowspan="4">Clinical dysfunction index, Code:</td> <td>0 points — clinically symptom free — D, O</td> </tr> <tr> <td>1-4 points — mild dysfunction — D, I</td> </tr> <tr> <td>5-9 points — moderate dysfunction — D, II</td> </tr> <tr> <td>10-25 points — severe dysfunction — D, III</td> </tr> <tr> <td></td> <td></td> </tr> <tr> <td></td> <td></td> </tr> <tr> <td></td> <td></td> </tr> </table> <p>Present occlusal scheme: ______</p> <hr>   #### Anamnestic Dysfunction Index (Helkimo 1974) - **A, O** – denotes complete absence of subjective symptoms of dysfunction of the masticatory system - **A, I** – denotes mild symptoms such as temporomandibular joint sounds (clicking, crepitation), feeling of stiffness or fatigue of the jaws - **A, II** – denotes severe symptom of dysfunction. One or more of the following symptoms reported: difficulty opening the mouth wide, locking, luxations, pain on movement, facial and jaw pain | Date | | | | |------|-----|-----|-----| | | | | | | | | | | | | | | | | | | | | #### Clinical Dysfunction Index – Based on evaluation of five common symptoms **A. Impaired range of movement/mobility index** - Normal range of movement – 0 - Slightly impaired mobility – 1 - Severely impaired mobility – 5 **B. Impaired TM joint function** - Smooth movement without TM joint sounds and deviation on opening/closing movements < 2 mm – 0 - TM joint sounds in one or both joints and/or deviation ≥ 2 mm on opening/closing movements – 1 - Locking and/or luxation of the TM joint – 5 **C. Muscle pain** - No tenderness to palpation in masticatory muscles – 0 - Tenderness to palpation in 1–3 palpation sites – 1 - Tenderness to palpation in 4 or more palpation sites – 5 **D. Temporomandibular joint pain** - No tenderness to palpation – 0 - Tenderness to palpation laterally – 1 - Tenderness to palpation posteriorly – 5 **E. Pain on movement of the mandible** - No pain on movement – 0 - Pain on 1 movement – 1 - Pain on 2 or more movements – 5 **F.** Sum A + B + C + D + E = dysfunction score (0–25 points) **G. Clinical dysfunction index, Code:** - 0 points – clinically symptom free – D, O - 1–4 points – mild dysfunction – D, I - 5–9 points – moderate dysfunction – D, II - 10–25 points – severe dysfunction – D, III Present occlusal scheme: ______ Table labeled 'Anamnestic Dysfunction Index, A. (Helkimo 1974)' with three rows defining severity levels: 'A, O' for complete absence of symptoms, 'A, I' for mild symptoms like joint sounds or stiffness, and 'A, II' for severe symptoms including locking or pain. The table includes a column for dates. Table titled 'Clinical Dysfunction Index, D. Based on evaluation of five common symptoms'. It lists five symptom categories (A-E): Impaired range of movement/mobility index, Impaired TM joint function, Muscle pain, Temporomandibular joint pain, and Pain on movement of the mandible. Each category has specific criteria and associated scores (0, 1, or 5). Below this is row F for summing the dysfunction score and row G for clinical dysfunction index codes based on points. **Form 29** Occlusion / TMJ Examination *continuation* 1. Max. opening in mm \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 2. Max. opening at active stretch \_\_\_\_\_\_\_\_\_\_ 3. Deviation on opening 4. Movement to Right / Left / Protrusion 5. Slide from RCP to ICP Anterior component \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ mm Vertical component \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ mm Horizontal component \_\_\_\_\_\_\_\_\_\_ mm R or L <table> <thead> <tr> <th colspan="16">Terminal Hinge Axis Initial Contact</th> </tr> </thead> <tbody> <tr><td>18</td><td>17</td><td>16</td><td>15</td><td>14</td><td>13</td><td>12</td><td>11</td><td>21</td><td>22</td><td>23</td><td>24</td><td>25</td><td>26</td><td>27</td><td>28</td></tr> <tr><td>48</td><td>47</td><td>46</td><td>45</td><td>44</td><td>43</td><td>42</td><td>41</td><td>31</td><td>32</td><td>33</td><td>34</td><td>35</td><td>36</td><td>37</td><td>38</td></tr> </tbody> </table> <table> <thead> <tr> <th colspan="16">Intercuspal Position Contacts</th> </tr> </thead> <tbody> <tr><td>18</td><td>17</td><td>16</td><td>15</td><td>14</td><td>13</td><td>12</td><td>11</td><td>21</td><td>22</td><td>23</td><td>24</td><td>25</td><td>26</td><td>27</td><td>28</td></tr> <tr><td>48</td><td>47</td><td>46</td><td>45</td><td>44</td><td>43</td><td>42</td><td>41</td><td>31</td><td>32</td><td>33</td><td>34</td><td>35</td><td>36</td><td>37</td><td>38</td></tr> </tbody> </table> <table> <thead> <tr> <th colspan="16">Laterotrusive Contacts</th> </tr> </thead> <tbody> <tr><td>18</td><td>17</td><td>16</td><td>15</td><td>14</td><td>13</td><td>12</td><td>11</td><td>21</td><td>22</td><td>23</td><td>24</td><td>25</td><td>26</td><td>27</td><td>28</td></tr> <tr><td>48</td><td>47</td><td>46</td><td>45</td><td>44</td><td>43</td><td>42</td><td>41</td><td>31</td><td>32</td><td>33</td><td>34</td><td>35</td><td>36</td><td>37</td><td>38</td></tr> </tbody> </table> <table> <thead> <tr> <th colspan="16">Mediotrusive Interferences</th> </tr> </thead> <tbody> <tr><td>18</td><td>17</td><td>16</td><td>15</td><td>14</td><td>13</td><td>12</td><td>11</td><td>21</td><td>22</td><td>23</td><td>24</td><td>25</td><td>26</td><td>27</td><td>28</td></tr> <tr><td>48</td><td>47</td><td>46</td><td>45</td><td>44</td><td>43</td><td>42</td><td>41</td><td>31</td><td>32</td><td>33</td><td>34</td><td>35</td><td>36</td><td>37</td><td>38</td></tr> </tbody> </table> <table> <thead> <tr> <th colspan="16">Protrusive Contacts</th> </tr> </thead> <tbody> <tr><td>18</td><td>17</td><td>16</td><td>15</td><td>14</td><td>13</td><td>12</td><td>11</td><td>21</td><td>22</td><td>23</td><td>24</td><td>25</td><td>26</td><td>27</td><td>28</td></tr> <tr><td>48</td><td>47</td><td>46</td><td>45</td><td>44</td><td>43</td><td>42</td><td>41</td><td>31</td><td>32</td><td>33</td><td>34</td><td>35</td><td>36</td><td>37</td><td>38</td></tr> </tbody> </table> <table> <thead> <tr> <th colspan="16">Bruxofacets</th> </tr> </thead> <tbody> <tr><td>18</td><td>17</td><td>16</td><td>15</td><td>14</td><td>13</td><td>12</td><td>11</td><td>21</td><td>22</td><td>23</td><td>24</td><td>25</td><td>26</td><td>27</td><td>28</td></tr> <tr><td>48</td><td>47</td><td>46</td><td>45</td><td>44</td><td>43</td><td>42</td><td>41</td><td>31</td><td>32</td><td>33</td><td>34</td><td>35</td><td>36</td><td>37</td><td>38</td></tr> </tbody> </table> <table> <thead> <tr> <th colspan="16">Fremitus at Intercuspal Position</th> </tr> </thead> <tbody> <tr><td>18</td><td>17</td><td>16</td><td>15</td><td>14</td><td>13</td><td>12</td><td>11</td><td>21</td><td>22</td><td>23</td><td>24</td><td>25</td><td>26</td><td>27</td><td>28</td></tr> <tr><td>48</td><td>47</td><td>46</td><td>45</td><td>44</td><td>43</td><td>42</td><td>41</td><td>31</td><td>32</td><td>33</td><td>34</td><td>35</td><td>36</td><td>37</td><td>38</td></tr> </tbody> </table> <table> <thead> <tr> <th colspan="16">Fremitus in Lateral Excursions</th> </tr> </thead> <tbody> <tr><td>18</td><td>17</td><td>16</td><td>15</td><td>14</td><td>13</td><td>12</td><td>11</td><td>21</td><td>22</td><td>23</td><td>24</td><td>25</td><td>26</td><td>27</td><td>28</td></tr> <tr><td>48</td><td>47</td><td>46</td><td>45</td><td>44</td><td>43</td><td>42</td><td>41</td><td>31</td><td>32</td><td>33</td><td>34</td><td>35</td><td>36</td><td>37</td><td>38</td></tr> </tbody> </table> In the final assessment as to whether or not the patient has a problem related to occlusion, consider the following questions: 1. Can the patient breathe properly? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 2. Can the patient chew adequately? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 3. Is the patient aesthetically satisfied? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 4. Is the phonetic pattern acceptable? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 5. Is the patient in periodontal health? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 6. Is the patient free of TMJ signs and symptoms? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 7. Is there an absence of retrograde patterns and wear? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 8. Is there a negative occlusal sense? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ <table> <tbody> <tr> <td>Clinician Signature:</td> <td>Clinician ID:</td> <td>Date:</td> </tr> <tr> <td>Supervisor Signature:<br>(If student clinician)</td> <td>Supervisor ID:</td> <td></td> </tr> </tbody> </table>           #### Mandibular Range of Motion and Deviation 1. Max. opening in mm \_\_\_\_\_\_\_\_\_\_ 2. Max. opening at active stretch \_\_\_\_\_\_\_\_\_\_ 3. Deviation on opening 4. Movement to Right / Left / Protrusion 5. Slide from RCP to ICP - Anterior component \_\_\_\_\_\_\_\_\_\_ mm - Vertical component \_\_\_\_\_\_\_\_\_\_ mm - Horizontal component \_\_\_\_\_\_ mm R or L #### Occlusal Analysis and Terminal Hinge Position **Terminal Hinge Axis Initial Contact** | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | |----|----|----|----|----|----|----|----|----|----|----|----|----|----|----|----| | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | **Intercuspal Position Contacts** | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | |----|----|----|----|----|----|----|----|----|----|----|----|----|----|----|----| | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | **Laterotrusive Contacts** | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | |----|----|----|----|----|----|----|----|----|----|----|----|----|----|----|----| | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | **Mediotrusive Interferences** | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | |----|----|----|----|----|----|----|----|----|----|----|----|----|----|----|----| | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | **Protrusive Contacts** | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | |----|----|----|----|----|----|----|----|----|----|----|----|----|----|----|----| | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | **Bruxofacets** | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | |----|----|----|----|----|----|----|----|----|----|----|----|----|----|----|----| | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | **Fremitus at Intercuspal Position** | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | |----|----|----|----|----|----|----|----|----|----|----|----|----|----|----|----| | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | **Fremitus in Lateral Excursions** | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | |----|----|----|----|----|----|----|----|----|----|----|----|----|----|----|----| | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | In the final assessment as to whether or not the patient has a problem related to occlusion, consider the following questions: 1. Can the patient breathe properly? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 2. Can the patient chew adequately? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 3. Is the patient aesthetically satisfied? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 4. Is the phonetic pattern acceptable? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 5. Is the patient in periodontal health? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 6. Is the patient free of TMJ signs and symptoms? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 7. Is there an absence of retrograde patterns and wear? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 8. Is there a negative occlusal sense? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | Clinician Signature: | Clinician ID: | Date: | |---------------------|---------------|-------| | Supervisor Signature: (If student clinician) | Supervisor ID: | | Labeled grid diagram for occlusion recording. The grid is divided into four quadrants labeled 'R' (Right) on the left side and 'L' (Left) on the right side. The horizontal axis is marked with values '20' at both ends. Movement graph illustrating jaw movement to Right / Left / Protrusion. A central vertical line connects points labeled 20, 10, 5, 5, 10, 15, and 15, representing degrees of movement. Table showing tooth numbering layout (18-11 upper arch, 48-31 lower arch) used for marking initial contact points during hinge axis examination. Table showing tooth numbering layout (18-11 upper arch, 48-31 lower arch) used for marking intercuspal position contacts. Table showing tooth numbering layout (18-11 upper arch, 48-31 lower arch) used for marking laterotrusive contacts. Table showing tooth numbering layout (18-11 upper arch, 48-31 lower arch) used for marking mediotrusive interferences. Table showing tooth numbering layout (18-11 upper arch, 48-31 lower arch) used for marking protrusive contacts. Table showing tooth numbering layout (18-11 upper arch, 48-31 lower arch) used for marking bruxofacets. Table showing tooth numbering layout (18-11 upper arch, 48-31 lower arch) used for marking fremitus at intercuspal position. Table showing tooth numbering layout (18-11 upper arch, 48-31 lower arch) used for marking fremitus in lateral excursions. [^1]: Original PDF page 1: [[Form 29 - Occlusion_TMJ Examination.pdf#page=1|Form 29 - Occlusion TMJ Examination, p.1]] [^2]: Original PDF page 2: [[Form 29 - Occlusion_TMJ Examination.pdf#page=2|Form 29 - Occlusion TMJ Examination, p.2]]