# HISTORY & EXAMINATION INCLUDING DC/TMD **Ramesh Balasubramaniam OAM** **DENT5310** **Orofacial Pain and Dental Sleep Medicine Module** **16th April 2026** **Ramesh Balasubramaniam OAM** **DENT5310** **Orofacial Pain and Dental Sleep Medicine Module** **16th April 2026** # **DISCLOSURES** ## Ramesh Balasubramaniam OAM Associate Professor Discipline Lead in Oral Medicine UWA Dental School The University of Western Australia Neither I nor my immediate family have any financial interests that would create a conflict of interest or restrict my independent judgment with regard to the content of this presentation. #### Presenter Information **Ramesh Balasubramaniam OAM** Associate Professor Discipline Lead in Oral Medicine UWA Dental School The University of Western Australia #### Conflict of Interest Statement Neither I nor my immediate family have any financial interests that would create a conflict of interest or restrict my independent judgment with regard to the content of this presentation. “Temporomandibular Disorders (TMD) is a collective term for a group of musculoskeletal and neuromuscular conditions which includes several clinical signs and symptoms involving the muscles of mastication, the temporomandibular joint and associated structures”– DC/TMD “Temporomandibular Disorders (TMD) is a collective term for a group of musculoskeletal and neuromuscular conditions which includes several clinical signs and symptoms involving the muscles of mastication, the temporomandibular joint and associated structures” – DC/TMD # TEMPOROMANDIBULAR JOINT ## Anatomy Farah CS, Balasubramaniam R, McCullough MJ, editors. *Contemporary Oral Medicine*. Cham (Switzerland): Springer; 2019. p. 2406. ### Overview * Two incongruent parts: Mandibular condyle + Glenoid fossa * Articular disc positioned between the condyle and fossa * Disc divides the joint cavity into upper and lower compartments * Central part of the disc: Avascular, not innervated * Retrodiscal tissue: Highly innervated and vascularised ## Label Guide | Label | Description | | :--- | :--- | | (E) | Articular eminence | | (C) | Condyle | | (L) | Lower joint space | | (D) | Articular disc | | (U) | Upper joint space | | (B) | Retrodiscal tissue |  #### Anatomical Overview - Two incongruent parts: Mandibular condyle and Glenoid fossa - Articular disc positioned between the condyle and fossa - Disc divides the joint cavity into upper and lower compartments - Central part of the disc: Avascular, not innervated - Retrodiscal tissue: Highly innervated and vascularised #### Anatomical Label Guide - (E) Articular eminence - (C) Condyle - (L) Lower joint space - (D) Articular disc - (U) Upper joint space - (B) Retrodiscal tissue Labelled clinical photograph of the temporomandibular joint (TMJ) anatomy. The image displays the condyle and glenoid fossa with the articular disc positioned between them. It is annotated with black leader lines pointing to specific structures: 'Articular eminence' (E), 'Condyle' (C), 'Lower joint space' (L), 'Articular disc' (D), 'Upper joint space' (U), and 'Retrodiscal tissue'. A green text box on the right provides a bulleted summary of the joint's components and characteristics. <div> <table> <tr> <td> <h2>TEMPOROMANDIBULAR JOINT</h2> </td> </tr> <tr> <td></td> </tr> <tr> <td style="text-align: center;"><b>Capsule</b></td> </tr> <tr> <td></td> </tr> <tr> <td> <ul> <li>Joint is encapsulated by a fibrous capsule</li> <li>Attached to temporal bone along fossa and condyle</li> <li>Loose arrangement of connective tissue</li> </ul> </td> </tr> <tr> <td> <small>Farah CS, Balasubramaniam R, McCullough MJ, editors. Contemporary Oral Medicine. Cham (Switzerland): Springer; 2019. p. 2406.</small> </td> </tr> </table> </div>  #### Characteristics of the Joint Capsule - Joint is encapsulated by a fibrous capsule - Attached to temporal bone along fossa and condyle - Loose arrangement of connective tissue Anatomical diagram of the Temporal Mandibular Joint showing a lateral view of the skull. Key features include a yellow highlighted section labeled 'C' indicating the Capsule. A black arrow points from the text label 'Capsule' to the highlighted area. Other anatomical landmarks are marked with abbreviations: 'ZA' (Zygomatic Arch), 'CP' (Condylar Process), and 'M' (Mandible).   Lateral view diagram of the skull showing masticatory muscles. Labels point to 'Temporalis muscle', 'Zygomatic arch', and 'Masseter muscle'. Lateral view diagram of the skull highlighting deep masticatory muscles. Labels point to 'Upper and lower head of Lateral pterygoid' and 'Deep and superficial head of Medial pterygoid'. # AETIOLOGY AND RISK FACTORS OF TMD ### Historically Thought that TMD caused by occlusal factors Resulted in therapies involving changing the patient’s occlusion Historically, it was thought that TMD was caused by occlusal factors. This perspective resulted in therapies involving changing the patient’s occlusion. # **AETIOLOGY AND RISK FACTORS OF TMD** ## **THE BIG PICTURE** * occlusion can't contribute to TMD * 2 Principal Intermediate Phenotypes contribute to onset and persistent (constellation of risk factors). * Genetic regulation * Environmental contributions interact with Intermediate Phenotypes to contribute to onset and persistent. * TIME | ENVIRONMENTAL<br>CONTRIBUTIONS | | | | | :--- | :--- | :--- | :--- | | Physical | trauma | abuse | infection<br>smoking | | Psychological | life stressors | | | | Culture | health beliefs | | | | **High Psychological Distress** | <==> | **High State of Pain Amplification** | | :--- | :--- | :--- | | ^ Mood <br> ^ Anxiety <br> ^ Depression <br> ^ Stress<br> response <br> ^ Somatization | | ^ Neuro-<br> endocrine<br> function <br> ^ Autonomic<br> function <br> ^ Impaired<br> pain<br> regulation <br> ^ Pro-<br> inflammatory<br> state | | Painful | Persistent<br>CPPC | Transient<br>CPPC | Subclinical signs &<br>symptoms | | :---: | :--- | :--- | :--- | | CPPCs | | | | | GAD65<br>MAO | Serotonin<br>receptor | Cannabinoid<br>receptors<br>NMDA | Dopamine<br>receptors<br>CREB1 | Adrenergic<br>receptors<br>GR | Serotonin<br>transporter | CACNA1A<br>DREAM | NET<br>POMC | Opioid<br>receptors | Na<sup>+<br>, K<sup>+<br>ATPase<br>BDNF<br>NGF | IKK<br>Prodynorphin | COMT<br>Interleukins | | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | | ^<br>^<br> | ^<br>^<br> | ^<br>^<br> | ^<br>^<br> | ^<br>^<br> | ^<br>^<br> | ^<br>^<br> | ^<br>^<br> | ^<br>^<br> | ^<br>^<br> | ^<br>^<br> | ^<br>^<br> | | Xp11.23<br>| | 12q11.2<br>| | 9q34.3<br>| | 11q23<br>| | 5q31-q32<br>| | 5q31-32<br>| | 6q24-q25<br>| | 1p13.1<br>| | 22q11.21<br>| | Maixner W, Fillingim RB, Williams DA, Smith SB, Slade GD. Overlapping Chronic Pain Conditions: Implications for Diagnosis and Classification. J Pain. 2016;17(9<br>Suppl):T93-T107.  #### Risk Factors and Phenotypes - Occlusion is not considered a contributor to TMD. - Two principal intermediate phenotypes contribute to onset and persistence (constellation of risk factors). - Genetic regulation and environmental contributions interact with intermediate phenotypes to contribute to onset and persistence. - Time is a critical factor. #### Environmental Contributions - **Physical:** Trauma, abuse, infection, smoking - **Psychological:** Life stressors - **Culture:** Health beliefs #### Psychological Distress and Pain Amplification High Psychological Distress correlates with a High State of Pain Amplification: - **Psychological Factors:** Increased mood disturbances, anxiety, depression, stress response, and somatization. - **Physiological Factors:** Increased neuroendocrine function, autonomic function, impaired pain regulation, and pro-inflammatory state. #### Clinical Presentations - Painful Chronic Overlapping Pain Conditions (COPCs) - Persistent CPPC - Transient CPPC - Subclinical signs and symptoms #### Genetic Markers Various genetic markers and receptors are associated with these conditions, including: - GAD65, MAO, Serotonin receptors/transporters, Cannabinoid receptors, NMDA, Dopamine receptors, CREB1, Adrenergic receptors, GR, CACNA1A, DREAM, NET, POMC, Opioid receptors, Na+, K+ ATPase, BDNF, NGF, IKK, Prodynorphin, COMT, and Interleukins. Complex causal pathway diagram illustrating the etiology and risk factors of TMD. The diagram flows from 'Environmental Contributions' (Physical, Psychological, Culture) into two main intermediate phenotypes: 'High Psychological Distress' and 'High State of Pain Amplification'. These interact to lead to 'Painful CPPCs', which result in outcomes ranging from 'Persistent CPPC' to 'Subclinical signs & symptoms'. Below these pathways are genetic markers and chromosomal locations associated with neurotransmitter systems (e.g., Serotonin, Dopamine, Opioid receptors). **Contemporary evidence:** | Behavioral | Genetics | Psychological | |---|---|---| | Depression | 5 main gene polymorphisms | Affective distress | | Anxiety | Nociceptive pathways | | | Somatization | Inflammation | | | Catastrophising | | | | PTSD | | | | **Associated with risk of TMD onset & chronicity of TMD** | |\ |\ | | | |\ | | | | Sensory Processing | |---| | State of pain amplification | | Alterations in peripheral and central nervous system processes | | Net effect of amplifying response to nociceptive stimuli | | Consistent predictor of developing chronic TMD was presence of another chronic pain condition at baseline | | **Associated with risk of TMD onset and chronicity of TMD** |      #### Behavioral and Psychological Factors Factors associated with the risk of TMD onset and chronicity include: - Depression - Anxiety - Somatization - Catastrophising - PTSD - Affective distress #### Genetic and Biological Factors - 5 main gene polymorphisms - Nociceptive pathways - Inflammation #### Sensory Processing - State of pain amplification - Alterations in peripheral and central nervous system processes - Net effect of amplifying response to nociceptive stimuli - A consistent predictor of developing chronic TMD was the presence of another chronic pain condition at baseline. - These factors are associated with the risk of TMD onset and chronicity. Title banner figure with the text 'Contemporary evidence:' in white on a dark brown background. Table listing behavioral factors associated with TMD. Columns include 'Behavioral' (Depression, Anxiety, Somatization, Catastrophising, PTSD) and a note that these are 'Associated with risk of TMD onset & chronicity of TMD'. Diagram illustrating the 'Multifactorial Aetiology of' TMD. Central box surrounded by four contributing factors: Behavioral, Genetics, Psychological, and Sensory Processing, with arrows indicating their influence on the central condition. Table detailing sensory processing aspects related to TMD. Includes points on pain amplification, nervous system alterations, and predictors of chronic TMD development. Table summarizing genetic and psychological factors. Lists '5 main gene polymorphisms', 'Nociceptive pathways', 'Inflammation', 'Affective distress', and notes association with predicting TMD onset. # WHICH CLASSIFICATION AND DIAGNOSTIC CRITERIA WE USE? ```mermaid graph LR A((Most common TMD conditions)) --> B[Brief DC/TMD] C((Common TMD conditions)) --> D[DC/TMD] E((Less common orofacial pain/TMD conditions)) --> F[Expanding taxonomy of the DC/TMD] style A fill:#e8f5e9,stroke:#81c784 style C fill:#c8e6c9,stroke:#66bb6a style E fill:#bbdefb,stroke:#64b5f6 ``` **Handwritten Note:** For most practioners is adequate [referring to DC/TMD]  #### Selection of Diagnostic Framework The choice of diagnostic criteria depends on the prevalence and complexity of the condition: - **Brief DC/TMD**: Utilized for the most common TMD conditions. - **DC/TMD**: Utilized for common TMD conditions. (Note: For most practitioners, this framework is adequate). - **Expanding Taxonomy of the DC/TMD**: Utilized for less common orofacial pain and TMD conditions. A concentric circle diagram illustrating the hierarchy of TMD diagnostic criteria. The outermost blue ring is labeled 'Less common orofacial pain/TMD conditions' pointing to 'Expanding taxonomy of the DC/TMD'. The middle green ring is labeled 'Common TMD conditions' pointing to 'DC/TMD', which is circled in red ink. The innermost light green circle is labeled 'Most common TMD conditions' pointing to 'Brief DC/TMD'. A handwritten note in red ink at the bottom right states 'for most practioners is adequate' with an arrow pointing to the 'Brief DC/TMD' section. # DIAGNOSTIC CRITERIA FOR TEMPOROMANDIBULAR DISORDERS *J Oral Facial Pain Headache. 2014 ; 28(1): 6–27.* **Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†** * Dual axis diagnostic criteria * Axis I: Physical diagnoses for most common pain & non-pain related TMDs * Axis II: Biobehavioural assessments of patient's pain disorder * Graded chronic pain scale: measures pain related intensity and disability * Standardized, reliable protocol – achieving Sn 80% – 90% * Low specificity for disc displacements as it relies solely on clinical examination – CT/MRI * Expanded taxonomy for less common disorders act only as preliminary diagnosis Available for download: https://ubwp.buffalo.edu/rdc-tmdinternational/ #### Dual Axis Diagnostic Criteria The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) provides a standardized, reliable protocol (achieving 80%–90% sensitivity) for clinical and research applications. - **Axis I: Physical Diagnoses** - Covers the most common pain and non-pain related TMDs. - Note: Relies on clinical examination; has low specificity for disc displacements compared to CT/MRI. - **Axis II: Biobehavioral Assessments** - Evaluates the patient's pain disorder. - Includes the Graded Chronic Pain Scale to measure pain intensity and disability. #### Implementation Notes - **Expanded Taxonomy**: Serves as a preliminary diagnosis for less common disorders. - **Resources**: Documentation is available for download at the International RDC/TMD Consortium Network website. Text-based procedure outlining the 'Dual axis diagnostic criteria' for Temporomandibular Disorders (DC/TMD). It details Axis I for physical diagnoses and Axis II for biobehavioural assessments. The list includes specific points on the graded chronic pain scale, standardized protocols with sensitivity metrics (Sn 80%–90%), limitations regarding disc displacement specificity without imaging (CT/MRI), and the role of expanded taxonomy as preliminary diagnosis. | | History | | Examination | | | :--- | :--- | :--- | :--- | :--- | | | **Criteria** | **SQ** | **Criteria** | **Examination Form** | | **Pain Disorders** | | | | | | Myalgia (ICD-9 729.1) | Pain in a masticatory structure | SQ3 | Confirmation of pain in masticatory muscle(s) | E1a | | * Sens 0.90 | Pain modified by jaw movement, function, or parafunction | SQ4 | Familiar pain in masticatory muscle(s) with either muscle palpation or maximum opening | E4b, E4c, or E9: familiar pain in temporalis or masseter, or in other masticatory muscles if also relevant; **or** <br> E10: familiar pain in supplemental muscles, if E10 included | | * Spec 0.95 | | | | | | Myalgia Subtypes | | | | | | **Local Myalgia** (ICD-9 729.1) | [same as for Myalgia] | [SQ3 & SQ4] | Confirmation of pain in masticatory muscle(s) | E1a | | Sens and Spec not established | | | Familiar pain with muscle palpation | **E9: familiar pain in masseter or temporalis; *or*** <br> **E10: familiar pain in supplemental muscles, if E10 included** | | | | | Pain remains local to the area of stimulation | **E9: negative referred and spreading pain; and** <br> **E10: negative referred and spreading pain, if E10 included** | | **Myofascial Pain with Spreading** (ICD-9 729.1) | [same as for Myalgia] | [SQ3 & SQ4] | Confirmation of pain in masticatory muscle(s) | E1a | | Sens and Spec not established | | | Familiar pain with muscle palpation | **E9: familiar pain in masseter or temporalis; *or*** <br> **E10: familiar pain in supplemental muscles, if E10 included** | | | | | Spreading (but not referred) pain with muscle palpation | **E9: spreading pain; or** <br> **E10: spreading pain, if E10 included; AND** <br> **E9: negative referred pain; and** <br> **E10: negative referred pain, if E10 included** |  #### Myalgia (ICD-9 729.1) - **History Criteria**: Pain in a masticatory structure (SQ3) modified by jaw movement, function, or parafunction (SQ4). - **Examination Criteria**: Confirmation of pain in masticatory muscle(s) (E1a) and familiar pain in the temporalis or masseter with palpation or maximum opening (E4b, E4c, E9, or E10). - **Statistics**: Sensitivity 0.90; Specificity 0.95. #### Myalgia Subtypes ##### Local Myalgia - **History**: Same as Myalgia (SQ3 & SQ4). - **Examination**: Familiar pain with muscle palpation (E9 or E10) that remains local to the area of stimulation (negative referred and spreading pain). ##### Myofascial Pain with Spreading - **History**: Same as Myalgia (SQ3 & SQ4). - **Examination**: Familiar pain with muscle palpation (E9 or E10) and spreading pain (but not referred pain) with muscle palpation. A comprehensive clinical reference table titled 'Pain Disorders' comparing diagnostic criteria for Myalgia and its subtypes (Local Myalgia and Myofascial Pain with Spreading). The table is organized into five columns: Disorder, History Criteria, SQ (Screening Questions), Examination Criteria, and Examination Form codes. It details specific conditions such as ICD-9 code 729.1, sensitivity/specificity values (Sens 0.90, Spec 0.95), and distinct examination findings like familiar pain in masticatory muscles versus spreading or referred pain patterns. | Disorder | History Criteria | History SQ | Examination Criteria | Examination Form | | :--- | :--- | :--- | :--- | :--- | | **Myofascial Pain with Referral**<br>(ICD-9 729.1)<br>• Sens 0.86<br>• Spec 0.98 | [same as for Myalgia] | [SQ3 & SQ4] | Confirmation of pain in masticatory muscle(s) | E1a | | | | | Familiar pain with muscle palpation | **E9:** familiar pain in masseter or temporalis; **or**<br>**E10:** familiar pain in supplemental muscles, if E10 included | | | | | Referred pain with muscle palpation | **E9:** positive referred pain; **or**<br>**E10:** positive referred pain, if E10 included | | **Arthralgia**<br>(ICD-9 524.62)<br>• Sens 0.89<br>• Spec 0.98 | Pain in a masticatory structure | SQ3 | Confirmation of pain in TMJ(s) | E1a | | | Pain modified by jaw movement, function, or parafunction | SQ4 | Familiar pain with TMJ palpation or range of motion | E4b, E4c, E5a-c, or E9: familiar pain in TMJ | | **Headache Attributed to TMD**<br>(ICD-9 339.89 [other specified headache syndrome], or ICD-9 784.0 [headache])<br>• Sens 0.89<br>• Spec 0.87 | Headache of any type in temporal region | SQ5 | Confirmation of headache in temporalis muscle | E1b | | | Headache affected by jaw movement, function, or parafunction | SQ7 | Report of familiar headache in temporalis area from either:<br>a. Palpation of the temporalis muscle **or**<br>b. Range of motion of jaw | E4b, E4c, E5a-c, or E9: familiar headache pain in the temporalis muscle | > Note that for a secondary headache diagnosis, a primary diagnosis of either myalgia or arthralgia is required.  #### Myofascial Pain with Referral (ICD-9 729.1) - **History**: Same as Myalgia (SQ3 & SQ4). - **Examination**: Confirmation of pain in masticatory muscle(s) (E1a) and familiar pain with muscle palpation (E9 or E10) resulting in positive referred pain. - **Statistics**: Sensitivity 0.86; Specificity 0.98. #### Arthralgia (ICD-9 524.62) - **History**: Pain in a masticatory structure (SQ3) modified by jaw movement, function, or parafunction (SQ4). - **Examination**: Confirmation of pain in TMJ(s) (E1a) and familiar pain with TMJ palpation or range of motion (E4b, E4c, E5a-c, or E9). - **Statistics**: Sensitivity 0.89; Specificity 0.98. #### Headache Attributed to TMD (ICD-9 339.89 or 784.0) - **History**: Headache of any type in the temporal region (SQ5) affected by jaw movement, function, or parafunction (SQ7). - **Examination**: Confirmation of headache in the temporalis muscle (E1b) and report of familiar headache in the temporalis area from palpation or range of motion (E4b, E4c, E5a-c, or E9). - **Statistics**: Sensitivity 0.89; Specificity 0.87. - **Note**: A secondary headache diagnosis requires a primary diagnosis of either myalgia or arthralgia. A structured table detailing diagnostic criteria for three disorders: Myofascial Pain with Referral, Arthralgia, and Headache Attributed to TMD. The table is organized into columns for Disorder (including ICD-9 codes and Sensitivity/Specificity metrics), History Criteria and associated Survey Questions (SQ), Examination Criteria, and Examination Form references. It visually maps clinical history questions against physical examination findings required for diagnosis. ```html <table border="1"> <tr> <td rowspan="5"></td> <th colspan="2">History</th> <th colspan="2">Examination</th> </tr> <tr> <th>Disorder</th> <th>Criteria</th> <th>SQ</th> <th>Criteria</th> <th>Examination Form</th> </tr> <tr> <td colspan="5">Joint Disorders</td> </tr> <tr> <td rowspan="2">Disc Displacement with Reduction<br>(ICD-9 524.63)<br>• Sens 0.34<br>• Spec 0.92</td> <td>Current TMJ noises by history, OR</td> <td>SQ8</td> <td>Click(s) with opening and closing, OR</td> <td>E6: (open & close) click, OR</td> </tr> <tr> <td>Patient reports noise during the examination</td> <td>E6 or E7: noise reported by patient</td> <td>Both (a) click with opening or closing, and<br>(b) click with lateral or protrusive movements</td> <td>E6: (open or close) click, and<br>E7: (protrusive or lateral) click</td> </tr> <tr> <td rowspan="2">Disc Displacement with Reduction, with Intermittent Locking<br>(ICD-9 524.63)<br>• Sens 0.38<br>• Spec 0.98</td> <td>[same as disc displacement with reduction]</td> <td>[same as DD with red]</td> <td>[same as disc displacement with reduction]</td> <td>[same as DD with red]</td> </tr> <tr> <td>Current intermittent locking with limited opening</td> <td>SQ11=yes<br>SQ12=no</td> <td>When disorder present in clinic: maneuver required to open mouth</td> <td>E8 (optional)</td> </tr> <tr> <td rowspan="2">Disc Displacement without Reduction, with Limited Opening<br>(ICD-9 524.63)<br>• Sens 0.80<br>• Spec 0.97</td> <td>Current* TMJ lock with limited opening</td> <td>SQ9</td> <td>Passive stretch (maximum assisted opening) < 40mm</td> <td>E4c < 40mm including vertical incisal overlap</td> </tr> <tr> <td>Limation severe enough to interfere with ability to eat</td> <td>SQ10</td> <td></td> <td></td> </tr> <tr> <td rowspan="2">Disc Displacement without Reduction, without Limited Opening<br>(ICD-9 524.63)<br>• Sens 0.54<br>• Spec 0.79</td> <td>Prior* TMJ lock with limited opening</td> <td>SQ9</td> <td>Passive stretch (maximum assisted opening) >= 40mm</td> <td>E4c >= 40mm including vertical incisal overlap</td> </tr> <tr> <td>Limation severe enough to interfere with ability to eat</td> <td>SQ10</td> <td></td> <td></td> </tr> <tr> <td rowspan="2">Degenerative Joint Disease<br>(ICD-9 715.18)<br>• Sens 0.55<br>• Spec 0.61</td> <td>Current TMJ noises by history, OR</td> <td>SQ8</td> <td>Crepitus during jaw movement</td> <td>E6 or E7: crepitus detected by examiner</td> </tr> <tr> <td>Patient reports noise during the examination</td> <td>E6 or E7: noise reported by patient</td> <td></td> <td></td> </tr> <tr> <td rowspan="2">Subluxation<br>(ICD-9 830.0)<br>• Sens 0.98<br>• Spec 1.00</td> <td>TMJ locking or catching in wide open jaw position</td> <td>SQ13</td> <td>When disorder present in clinic: maneuver required to close mouth</td> <td>E8 (optional)</td> </tr> <tr> <td>Unable to close mouth without specific maneuver</td> <td>SQ14</td> <td></td> <td></td> </tr> <tr> <td colspan="5">“Current” and “Prior” (as based on S9) for distinguishing, respectively, the “with limitation” vs “without limitation” variants of Disc Displacement without Reduction are interpreted based on change over time as determined by history and as confirmed by the clinical examination for jaw range of motion.</td> </tr> </table> ```  #### Disc Displacement with Reduction (ICD-9 524.63) - **History**: Current TMJ noises (SQ8) or patient reports noise during examination. - **Examination**: Click(s) with opening and closing (E6), or click with opening/closing AND click with lateral/protrusive movements (E7). - **Statistics**: Sensitivity 0.34; Specificity 0.92. #### Disc Displacement with Reduction, with Intermittent Locking (ICD-9 524.63) - **History**: Same as DD with reduction, plus current intermittent locking with limited opening (SQ11=yes, SQ12=no). - **Examination**: Maneuver required to open mouth when disorder is present in clinic (E8). - **Statistics**: Sensitivity 0.38; Specificity 0.98. #### Disc Displacement without Reduction, with Limited Opening (ICD-9 524.63) - **History**: Current TMJ lock with limited opening (SQ9) severe enough to interfere with eating (SQ10). - **Examination**: Passive stretch (maximum assisted opening) < 40mm (E4c). - **Statistics**: Sensitivity 0.80; Specificity 0.97. #### Disc Displacement without Reduction, without Limited Opening (ICD-9 524.63) - **History**: Prior TMJ lock with limited opening (SQ9) severe enough to interfere with eating (SQ10). - **Examination**: Passive stretch (maximum assisted opening) ≥ 40mm (E4c). - **Statistics**: Sensitivity 0.54; Specificity 0.79. #### Degenerative Joint Disease (ICD-9 715.18) - **History**: Current TMJ noises (SQ8) or patient reports noise during examination. - **Examination**: Crepitus detected by examiner during jaw movement (E6 or E7). - **Statistics**: Sensitivity 0.55; Specificity 0.61. #### Subluxation (ICD-9 830.0) - **History**: TMJ locking or catching in wide open jaw position (SQ13) and unable to close mouth without specific maneuver (SQ14). - **Examination**: Maneuver required to close mouth when disorder is present in clinic (E8). - **Statistics**: Sensitivity 0.98; Specificity 1.00. A comprehensive clinical reference table titled 'Joint Disorders'. The table is structured with columns for 'Disorder', 'History' (Criteria and SQ), and 'Examination' (Criteria and Examination Form). It details diagnostic criteria for various Temporomandibular Joint (TMJ) conditions including Disc Displacement with/without Reduction, Degenerative Joint Disease, and Subluxation. Key data points include ICD-9 codes, Sensitivity/Specificity statistics, specific symptoms like clicking or crepitus, and physical exam findings such as jaw opening measurements (e.g., < 40mm). **I don't have** **to know** **EXPANDED TAXONOMY FOR TEMPOROMANDIBULAR DISORDERS** **I. TEMPOROMANDIBULAR JOINT DISORDERS** 1 Joint pain A. Arthralgia B. Arthritis 2 Joint disorders A. Disc disorders 1 Disc displacement with reduction 2 Disc displacement with reduction with intermittent locking 3 Disc displacement without reduction with limited opening 4 Disc displacement without reduction without limited opening B. Hypomobility disorders other than disc disorders 1 Adhesions/Adherence 2 Ankylosis a Fibrous b Osceous C. Hypermobility disorders 1 Dislocations a Subluxation b Luxation **3 Joint diseases** A Degenerative joint disease 1 Osteoarthrosis 2 Osteoarthritis B Systemic arthritides C Condylitis/Idiopathic condylar resorption D Osteochondritis dissecans E Osteonecrosis F Neoplasm G Synovial Chondromatosis **4 Fractures** **5 Congenital/developmental disorders** A Aplasia B Hypoplasia C Hyperplasia Peck CC, Goulet JP, Lobbezoo F, Schiffman EL, Alstergren P, Anderson GC, de Leeuw R, Jensen R, Michelotti A, Ohrbach R, Petersson A, List T. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. J Oral Rehabil. 2014 Jan;41(1):2-23. doi: 10.1111/joor.12132. #### I. Temporomandibular Joint Disorders 1. **Joint Pain** - A. Arthralgia - B. Arthritis 2. **Joint Disorders** - A. Disc disorders 1. Disc displacement with reduction 2. Disc displacement with reduction with intermittent locking 3. Disc displacement without reduction with limited opening 4. Disc displacement without reduction without limited opening - B. Hypomobility disorders other than disc disorders 1. Adhesions/Adherence 2. Ankylosis (Fibrous or Osseous) - C. Hypermobility disorders 1. Dislocations (Subluxation or Luxation) 3. **Joint Diseases** - A. Degenerative joint disease (Osteoarthrosis or Osteoarthritis) - B. Systemic arthritides - C. Condylitis/Idiopathic condylar resorption - D. Osteochondritis dissecans - E. Osteonecrosis - F. Neoplasm - G. Synovial Chondromatosis 4. **Fractures** 5. **Congenital/Developmental Disorders** - A. Aplasia - B. Hypoplasia - C. Hyperplasia II. MASTICATORY MUSCLE DISORDERS 1 Muscle pain A Myalgia 1 Local myalgia 2 Myofascial pain 3 Myofascial pain with referral B Tendonitis C Myositis D Spasm - extremely rare 2 Contracture 3 Hypertrophy 4 Neoplasm 5 Movement Disorders A Orofacial dyskinesia B Oromandibular dystonia 6 Masticatory muscle pain attributed to systemic/central pain disorders A Fibromyalgia/widespread pain III. HEADACHE 1 Headache attributed to TMD IV. ASSOCIATED STRUCTURES 1 Coronoid hyperplasia #### II. Masticatory Muscle Disorders 1. **Muscle Pain** - A. Myalgia (Local myalgia, Myofascial pain, Myofascial pain with referral) - B. Tendonitis - C. Myositis - D. Spasm (extremely rare) 2. **Contracture** 3. **Hypertrophy** 4. **Neoplasm** 5. **Movement Disorders** - A. Orofacial dyskinesia - B. Oromandibular dystonia 6. **Masticatory muscle pain attributed to systemic/central pain disorders** - A. Fibromyalgia/widespread pain #### III. Headache 1. **Headache attributed to TMD** #### IV. Associated Structures 1. **Coronoid hyperplasia** # HISTORY > “Nothing is more critical to success than beginning with all the necessary data”  > “Nothing is more critical to success than beginning with all the necessary data” Clinical photo: A dentist or hygienist wearing a white uniform and gloves is interacting with a young female patient seated in a blue dental chair. The patient is smiling while the professional appears to be examining her hand or performing a procedure. The background shows typical dental office equipment. # PAIN HISTORY ## The chief complaint * What brings you in today? * Can you describe **in your own words** what you're experiencing? **Pain location** **Pain onset** * Was there a trigger associated? #### Patient Interview - What brings you in today? - Can you describe **in your own words** what you're experiencing? #### Pain Characteristics - **Pain location** - **Pain onset** - Was there a trigger associated? ### PAIN HISTORY | Category | Details | | :--- | :--- | | **Pain Quality** | • Bright or dull; Pricking; Itching; Stinging; Burning; Aching; Pulsating; Throbbing | | **Pain behaviour** | • Temporal behaviour: frequency of pain; intermittent, continuous or persistent, recurrent<br>• Pain duration: momentary, longer lasting, protracted<br>• Localisation: localised, diffuse, radiating, spreading, enlarging, migrating | | **Pain intensity** | • Visual analogue scale or Numerical rating scale | | | No pain ------- X ------- Most severe pain |  #### Pain Quality - Bright or dull - Pricking - Itching - Stinging - Burning - Aching - Pulsating - Throbbing #### Pain Behavior - **Temporal behavior:** frequency of pain; intermittent, continuous or persistent, recurrent - **Pain duration:** momentary, longer lasting, protracted - **Localization:** localized, diffuse, radiating, spreading, enlarging, migrating #### Pain Intensity - Visual analogue scale or Numerical rating scale - No pain ------- X ------- Most severe pain Educational diagram titled 'PAIN HISTORY' illustrating three categories of pain assessment. The layout consists of dark teal headers on the left ('Pain Quality', 'Pain behaviour', 'Pain intensity') paired with green content boxes containing bullet points for each category. Under 'Pain intensity', a specific visual representation of a scale is included: a horizontal line labeled 'No pain' at the start and 'Most severe pain' at the end, with a red 'X' mark indicating a point on the scale. | PAIN HISTORY | | :--- | | Concomitant Symptoms | | • Sensory: hyperaesthesia, hypoaesthesia, anaesthesia, dysaesthesia, paraesthesia<br>• Motor: muscular weakness, muscular contractions, spasms<br>• Autonomic: lacrimation, pupillary changes, oedema of the lids, nasal secretions<br> | | Flow of Pain | | • Steady<br> • Paroxysmal | #### Concomitant Symptoms - **Sensory:** hyperaesthesia, hypoaesthesia, anaesthesia, dysaesthesia, paraesthesia - **Motor:** muscular weakness, muscular contractions, spasms - **Autonomic:** lacrimation, pupillary changes, oedema of the lids, nasal secretions #### Flow of Pain - Steady - Paroxysmal **PAIN HISTORY** **Effects of functional activities** * Pain when eating * Restriction in opening * Pain when yawning * **Jaw joint noises: Have you had any jaw joint noises when you moved or used your jaw?** * **Closed locking of the jaw: Have you ever had your jaw lock or catch, even for a moment, so that it would not open all the way? Was it sever enough to limit your ability to eat?** * **Open locking of the jaw: When you opened your mouth, did your jaw catch, even for a moment so that you could not close it from this wide position? Did you have to do something to get it to close?** * Headaches? #### Effects of Functional Activities - Pain when eating - Restriction in opening - Pain when yawning - **Jaw joint noises:** Have you had any jaw joint noises when you moved or used your jaw? - **Closed locking of the jaw:** Have you ever had your jaw lock or catch, even for a moment, so that it would not open all the way? Was it severe enough to limit your ability to eat? - **Open locking of the jaw:** When you opened your mouth, did your jaw catch, even for a moment so that you could not close it from this wide position? Did you have to do something to get it to close? - Headaches? **PAIN HISTORY** **Effects of parafunctional activities** • Awareness of day-time clenching • Grinding or clenching while asleep • Chin resting • Biting nails • Sleeping on stomach • Biting on back of pens/pencils • Chewing lips, cheeks, tongue  #### Effects of Parafunctional Activities - Awareness of day-time clenching - Grinding or clenching while asleep - Chin resting - Biting nails - Sleeping on stomach - Biting on back of pens/pencils - Chewing lips, cheeks, tongue Clinical photo showing a close-up profile of a person's face and hand. The individual is biting their fingernail or chewing on the side of their mouth, demonstrating a parafunctional activity related to jaw pain history. # in ochwa they still use the old index, rather do the DC/TMD # HISTORY PROTOCOL IN DC/TMD Note: In clinical practice, prioritize the DC/TMD protocol over older indices. #### History Protocol in DC/TMD # 3Q/TMD SCREENING QUESTIONS 1. Do you have pain in your temple, face, jaw or jaw joint once a week or more? 2. Do you have pain once a week or more when you open your mouth or chew? 3. Does your jaw lock or become stuck once a week or more? *\* Yes's in any of these indicate a high probability* Lövgren A, Parvaneh H, Lobbezoo F, Häggman-Henrikson B, Wänman A, Visscher CM. Diagnostic accuracy of three screening questions (3Q/TMD) in relation to the DC/TMD in a specialized orofacial pain clinic. Acta Odontol Scand. 2018 Aug;76(6):380-386. #### 3Q/TMD Screening Questions 1. Do you have pain in your temple, face, jaw or jaw joint once a week or more? 2. Do you have pain once a week or more when you open your mouth or chew? 3. Does your jaw lock or become stuck once a week or more? *Note: "Yes" responses to any of these indicate a high probability of TMD.* # Diagnostic Criteria for Temporomandibular Disorders ## Symptom Questionnaire | Patient name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | # PAIN 1. Have you ever had pain in your jaw, temple, in the ear, or in front of the ear on either side? No | Yes *If you answered NO, then skip to Question 5.* 2. How many years or months ago did your pain in the jaw, temple, in the ear, or in front of the ear first begin? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ years | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ months 3. In the last 30 days, which of the following best describes any pain in your jaw, temple, in the ear, or in front of the ear on either side? Select ONE response. * No pain * Pain comes and goes * Pain is always present *If you answered NO to Question 3, then skip to Question 5.* 4. In the last 30 days, did the following activities change any pain (that is, make it better or make it worse) in your jaw, temple, in the ear, or in front of the ear on either side? | | A. Chewing hard or tough food | No | Yes | |---|---|---|---| | | B. Opening your mouth, or moving your jaw forward or to the side | | | | | C. Jaw habits such as holding teeth together, clenching/grinding teeth, or chewing gum | | | | | D. Other jaw activities such as talking, kissing, or yawning | | |  #### DC/TMD Symptom Questionnaire: Pain 1. Have you ever had pain in your jaw, temple, in the ear, or in front of the ear on either side? - No / Yes (If NO, skip to Question 5) 2. How many years or months ago did your pain in the jaw, temple, in the ear, or in front of the ear first begin? - ____ years | ____ months 3. In the last 30 days, which of the following best describes any pain in your jaw, temple, in the ear, or in front of the ear on either side? - No pain (If NO, skip to Question 5) - Pain comes and goes - Pain is always present 4. In the last 30 days, did the following activities change any pain (make it better or worse) in your jaw, temple, in the ear, or in front of the ear on either side? - A. Chewing hard or tough food (No/Yes) - B. Opening your mouth, or moving your jaw forward or to the side (No/Yes) - C. Jaw habits such as holding teeth together, clenching/grinding teeth, or chewing gum (No/Yes) - D. Other jaw activities such as talking, kissing, or yawning (No/Yes) Table corresponding to Question 4 of the questionnaire. It lists four activities (A through D) related to jaw usage and asks whether they change pain. Columns include 'No' and 'Yes' checkboxes for each activity row. | **HEADACHE** | | :--- | | | | 5. In the last 30 days, have you had any headaches that included the temple areas of your head? | **No**              **Yes** | |         |    ☐ | No | | |         | | Yes | ☐ | | | | **If you answered NO to Question 5, then skip to Question 8.** | | | | | 6. How many years or months ago did your temple headache first begin? | \_\_\_\_\_\_\_\_ years     \_\_\_\_\_\_\_\_ months | | | | 7. In the last 30 days, did the following activities change any headache (that is, make it better or make it worse) in your temple area on either side? | **No** | **Yes** | | A. Chewing hard or tough food | ☐ | ☐ | | B. Opening your mouth, or moving your jaw forward or to the side | ☐ | ☐ | | C. Jaw habits such as holding teeth together, clenching/grinding, or chewing gum | ☐ | ☐ | | D. Other jaw activities such as talking, kissing, or yawning | ☐ | ☐ |  #### DC/TMD Symptom Questionnaire: Headache 5. In the last 30 days, have you had any headaches that included the temple areas of your head? - No / Yes (If NO, skip to Question 8) 6. How many years or months ago did your temple headache first begin? - ____ years | ____ months 7. In the last 30 days, did the following activities change any headache (make it better or worse) in your temple area on either side? - A. Chewing hard or tough food (No/Yes) - B. Opening your mouth, or moving your jaw forward or to the side (No/Yes) - C. Jaw habits such as holding teeth together, clenching/grinding, or chewing gum (No/Yes) - D. Other jaw activities such as talking, kissing, or yawning (No/Yes) A structured table containing Question 7 regarding jaw-related activities and their effect on temple headaches. The table lists four categories (A through D) including 'Chewing hard or tough food', 'Opening your mouth...', 'Jaw habits such as holding teeth together...', and 'Other jaw activities...'. For each category, there are two checkboxes labeled 'No' and 'Yes' to indicate if the activity made the headache better or worse. | **JAW JOINT NOISES** | **Office use** | |---|---| | 8. | In the last 30 days, have you had any jaw joint noise(s) when you moved or<br> | | used your jaw? | **No** | **Yes** | **R** | **L** | **DNK** | | | ☐ | ☐ | ☐ | ☐ | ☐ | |---|---|---|---|---|---| | **CLOSED LOCKING OF THE JAW** | | | | | | |---|---|---|---|---|---| | 9. | Have you **<u>ever</u>** had your jaw lock or catch, even for a moment, so that it would<br> **<u>not open</u>** **ALL THE WAY**? | ☐ | ☐ | ☐ | ☐ | ☐ | | | **If you answered NO to Question 9 then skip to Question 13.** | | | | | | | 10. | Was your jaw lock or catch severe enough to limit your jaw opening and<br>interfere with your ability to eat? | ☐ | ☐ | ☐ | ☐ | ☐ | | 11. | In the last 30 days, did your jaw lock so you could **<u>not open</u>** **ALL THE WAY**,<br>even for a moment, and then unlock so you could open **ALL THE WAY**? | ☐ | ☐ | ☐ | ☐ | ☐ | | | **If you answered NO to Question 11 then skip to Question 13.** | | | | | | | 12. | Is your jaw currently locked or limited so that your jaw will **<u>not open</u>** **ALL THE**<br>WAY? | ☐ | ☐ | ☐ | ☐ | ☐ |  #### DC/TMD Symptom Questionnaire: Jaw Joint Noises 8. In the last 30 days, have you had any jaw joint noise(s) when you moved or used your jaw? - No / Yes (Specify: Right, Left, or Don't Know) #### DC/TMD Symptom Questionnaire: Closed Locking 9. Have you **ever** had your jaw lock or catch, even for a moment, so that it would **not open ALL THE WAY**? - No / Yes (If NO, skip to Question 13) 10. Was your jaw lock or catch severe enough to limit your jaw opening and interfere with your ability to eat? - No / Yes 11. In the last 30 days, did your jaw lock so you could **not open ALL THE WAY**, even for a moment, and then unlock so you could open **ALL THE WAY**? - No / Yes (If NO, skip to Question 13) 12. Is your jaw currently locked or limited so that your jaw will **not open ALL THE WAY**? - No / Yes A clinical assessment table titled 'JAW JOINT NOISES' and 'CLOSED LOCKING OF THE JAW'. The table contains questions numbered 8 through 12. Question 8 asks about jaw joint noises in the last 30 days with options for No/Yes and a separate 'Office use' section for Right (R), Left (L), or Don't Know (DNK) side identification. Questions 9, 10, 11, and 12 address jaw locking and catching issues, including specific instructions to skip to Question 13 if answered 'NO'. Each row includes checkboxes for patient responses and corresponding boxes in the office use column. <table> <tbody> <tr> <td> <b> OPEN LOCKING OF THE JAW </b> </td> </tr> <tr> <td> 13. In the last 30 days, when you opened your mouth wide, did your jaw lock or catch even for a moment such that you could <b>not close</b> it from this wide open position? </td> <td> <p> ☐ <br/> ☐ <br/> ☐ </p> <p> ☐ <br/> ☐ <br/> ☐ </p> </td> </tr> <tr> <td> If you answered NO to Question 13 then you are finished. </td> </tr> <tr> <td> 14. In the last 30 days, when you jaw locked or caught wide open, did you have to do something to get it to close including resting, moving, pushing, or maneuvering it? </td> <td> <p> ☐ <br/> ☐ <br/> ☐ </p> <p> ☐ <br/> ☐ <br/> ☐ </p> </td> </tr> </tbody> </table> #### DC/TMD Symptom Questionnaire: Open Locking 13. In the last 30 days, when you opened your mouth wide, did your jaw lock or catch even for a moment such that you could **not close** it from this wide open position? - No / Yes (If NO, questionnaire is finished) 14. In the last 30 days, when your jaw locked or caught wide open, did you have to do something to get it to close including resting, moving, pushing, or maneuvering it? - No / Yes # MEDICAL & PSYCHOSOCIAL HISTORY ## **RB** ### Past Medical History ### Review of Systems ### Psychosocial History * Emotional stressors * Impact on quality of life * Impact on sleep quality ### Axis 2 * Pain manikin (1 item) * Graded Chronic Pain Scale * PHQ4 (4 items)  #### Clinical Assessment Components - **Past Medical History** - **Review of Systems** #### Psychosocial History - Emotional stressors - Impact on quality of life - Impact on sleep quality #### Axis 2 Assessment - Pain manikin (1 item) - Graded Chronic Pain Scale - PHQ4 (4 items) A flowchart-style diagram illustrating the components of a 'MEDICAL & PSYCHOSOCIAL HISTORY' assessment. It consists of four green parallelogram-shaped panels arranged horizontally from left to right: 1) 'Past Medical History', 2) 'Review of Systems', 3) 'Psychosocial History' (listing emotional stressors, impact on quality of life, and sleep quality), and 4) 'Axis 2' (listing Pain manikin, Graded Chronic Pain Scale, and PHQ4). A woman in casual clothing stands to the right of the fourth panel. ```html <div style="text-align: right; font-size: 14px; padding-right: 20px;">Patient Health Questionnaire - 4</div> <table border="1" style="width: 100%; border-collapse: collapse; margin-bottom: 20px;"> <thead> <tr> <th colspan="4" style="text-align: center; border-bottom: 2px solid black;">Over the last 2 weeks, how often have you been bothered by the following problems? Please place a check mark in the box to indicate your answer.</th> </tr> <tr> <th>Not at all</th> <th>Several days</th> <th>More than half the days</th> <th>Nearly every day</th> </tr> <tr> <td style="text-align: center;">0</td> <td style="text-align: center;">1</td> <td style="text-align: center;">2</td> <td style="text-align: center;">3</td> </tr> </thead> <tbody> <tr> <td><b>1.</b> Feeling nervous, anxious or on edge</td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> </tr> <tr> <td><b>2.</b> Not being able to stop or control worrying</td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> </tr> <tr> <td><b>3.</b> Little interest or pleasure in doing things</td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> </tr> <tr> <td><b>4.</b> Feeling down, depressed, or hopeless</td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> <td valign="middle" style="border: 1px solid black; width: 25px; height: 15px;"></td> </tr> <tr> <td colspan="5" style="background-color: #ddd; padding-left: 20px;"><b>TOTAL SCORE =                                  </b></td> </tr> </tbody> </table> <span style="position: absolute; bottom: 60px; right: 300px;"><table border="1" style="width: 50%; border-collapse: collapse;"> <thead> <tr> <th colspan="4" style="text-align: center; background-color: #ddd;">If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?</th> </tr> <tr> <th>Not difficult</th> <th>Somewhat</th> <th>Very</th> <th>Extremely</th> </tr> <tr> <td style="text-align: center;">at all</td> <td style="text-align: center;">difficult</td> <td style="text-align: center;">difficult</td> <td style="text-align: center;">difficult</td> </tr> </thead> <tbody> <tr> <td valign="middle" style="border: none; width: 20px;"></td> <td valign="middle" style="border: none; width: 20px;"></td> <td valign="middle" style="border: none; width: 20px;"></td> <td valign="middle" style="border: none; width: 20px;"></td> </tr> </tbody> </table></span> ```     #### Patient Health Questionnaire - 4 (PHQ-4) Over the last 2 weeks, how often have you been bothered by the following problems? (Scoring: 0 = Not at all; 1 = Several days; 2 = More than half the days; 3 = Nearly every day) 1. Feeling nervous, anxious or on edge 2. Not being able to stop or control worrying 3. Little interest or pleasure in doing things 4. Feeling down, depressed, or hopeless **TOTAL SCORE = ________** #### Functional Impact If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? - Not difficult at all - Somewhat difficult - Very difficult - Extremely difficult Pain drawing diagram showing five anatomical illustrations: a mouth with teeth, back view of a human body, front view of a human body, right side profile of a head, and left side profile of a head. The diagrams are used for patients to indicate pain locations by shading or marking specific areas. Graded Chronic Pain Scale - 30 days table containing six questions (Q1-Q6) asking patients to rate current/worst/average facial pain intensity and interference with daily activities/recreation/social life/work ability on a scale from 0-10. Includes calculation formulas for CPI (Chronic Pain Index) and Disability scores at the bottom. Patient Health Questionnaire - 4 table with four items assessing psychological distress over the last two weeks: feeling nervous/anxious, uncontrollable worrying, little interest in activities, and feeling depressed/hopeless. Uses frequency response options ranging from 'Not at all' to 'Nearly every day'. Includes total score field and follow-up question about difficulty level. Scoring interpretation chart showing color-coded ranges (green=0-20=None/Mild, yellow=20-60=Mild/Moderate, orange=60-80=Moderate, red=80-100=Severe) corresponding to pain intensity (CPI) and interference scores calculated from Q1-Q6. # EXAMINATION PROTOCOL | IN DC/TMD | | :--- | | • The default time frame for assessing pain in the expanded taxonomy is in “the last 30 days”; the examiner must identify with the patient all anatomical locations that they have experienced pain in the last 30 days. However, the examiner may choose a different time frame as dictated by clinical circumstances.<br>• For a given diagnosis, the location of pain induced by the specified provocation test(s) must be in an anatomical structure consistent with that diagnosis.<br>• “Familiar pain” or “familiar headache” is based on patient report that the pain induced by the specified provocation test(s) has replicated the patient’s pain, as identified by respective location and within the specified time frame (see note 1).<br>• The phrase “pain modified” is used in the diagnostic criteria for arthralgia and myofascial pain to emphasize that the pain may be made better or worse by jaw function, movement or parafunction, by history. The phrase is more inclusive than either phrase “pain made worse” or “pain made better” and is used to differentiate a musculoskeletal pain from other pain conditions of the trigeminal system.<br>• Whilst jaw muscle pain is diagnosed based on examination of the masseter and temporalis muscles, other masticatory muscles may be examined as required.<br>• Diagnostic imaging should only be considered after a history and physical examination indicates that information from imaging will influence patient care. Whilst guidelines have been provided for TMJ imaging (29 ;33 ), further research is needed.<br>• Magnetic resonance imaging (MRI) and computerized tomography (CT) are often the preferred imaging modalities. CT includes either conventional CT or cone beam computerized tomography (CBCT).<br>• Where intramuscular electromyography monitoring is indicated, this would be performed with fine wire or needle electrodes.<br>• For all pain-related diagnoses, the pain/headache is not better accounted for by another pain/headache diagnosis. | | Peck CC, Goulet JP, Lobbezoo F, Schiffman EL, Alstergren P, Anderson GC, de Leeuw R, Jensen R, Michelotti A, Ohrbach R, Petersson A, List T. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. J Oral Rehabil. 2014 Jan;41(1):2-23. doi: 10.1111/joor.12132. | #### General Assessment Guidelines - The default time frame for assessing pain in the expanded taxonomy is in “the last 30 days”; the examiner must identify with the patient all anatomical locations that they have experienced pain in the last 30 days. However, the examiner may choose a different time frame as dictated by clinical circumstances. - For a given diagnosis, the location of pain induced by the specified provocation test(s) must be in an anatomical structure consistent with that diagnosis. - “Familiar pain” or “familiar headache” is based on patient report that the pain induced by the specified provocation test(s) has replicated the patient’s pain, as identified by respective location and within the specified time frame. - The phrase “pain modified” is used in the diagnostic criteria for arthralgia and myofascial pain to emphasize that the pain may be made better or worse by jaw function, movement or parafunction, by history. The phrase is more inclusive than either phrase “pain made worse” or “pain made better” and is used to differentiate a musculoskeletal pain from other pain conditions of the trigeminal system. - Whilst jaw muscle pain is diagnosed based on examination of the masseter and temporalis muscles, other masticatory muscles may be examined as required. - Diagnostic imaging should only be considered after a history and physical examination indicates that information from imaging will influence patient care. - Magnetic resonance imaging (MRI) and computerized tomography (CT) are often the preferred imaging modalities. CT includes either conventional CT or cone beam computerized tomography (CBCT). - Where intramuscular electromyography monitoring is indicated, this would be performed with fine wire or needle electrodes. - For all pain-related diagnoses, the pain/headache is not better accounted for by another pain/headache diagnosis. | DC/TMD Examination Form | |---| | Patient _____________________________ | | Examiner ____________________________ Date filled out (mm-dd-yyyy) _______________ | | Item | Description | |---|---| | 1a. | Location of Pain: Last 30 days (Select all that apply) | | 1b. | Location of Headache: Last 30 days (Select all that apply) | | 2. | Incisal Relationships | **RIGHT PAIN** - ○ None - ○ Temporalis - ○ Other m muscles - ○ Non-mast - ○ Masseter - ○ TMJ - structures **LEFT PAIN** - ○ None - ○ Temporalis - ○ Other m muscles - ○ Non-mast - ○ Masseter - ○ TMJ - structures 1b. **Location of Headache: Last 30 days (Select all that apply)** - Left: ○ None, ○ Temporal, ○ Other 2. **Incisal Relationships** Reference tooth: ○ FDI #11, ○ FDI #21, ○ Other Horizontal Incisal Overjet ○ If negative | [ ] | mm Vertical Incisal Overlap ○ If negative | [ ] | mm Midline Deviation Right: ○ Left: ○ N/A: ○ [ ] | mm  #### Pain Location and Incisal Relationships **1a. Location of Pain: Last 30 days (Select all that apply)** - **Right Pain:** None, Temporalis, Masseter, TMJ, Other masticatory muscles, Non-masticatory structures - **Left Pain:** None, Temporalis, Masseter, TMJ, Other masticatory muscles, Non-masticatory structures **1b. Location of Headache: Last 30 days (Select all that apply)** - **Left:** None, Temporal, Other **2. Incisal Relationships** - **Reference tooth:** FDI #11, FDI #21, Other - **Horizontal Incisal Overjet:** [ ] mm (Note if negative) - **Vertical Incisal Overlap:** [ ] mm (Note if negative) - **Midline Deviation:** [ ] mm (Direction: Right, Left, or N/A) Clinical examination form table titled 'DC/TMD Examination Form'. The table is structured into three main sections. Section 1a ('Location of Pain') features a split layout with two columns labeled 'RIGHT PAIN' and 'LEFT PAIN', each containing radio button options for None, Temporalis, Other m muscles, Non-mast structures, Masseter, and TMJ. Section 1b ('Location of Headache') similarly splits into Left/Right options (None, Temporal, Other). Section 2 ('Incisal Relationships') includes fields for Reference tooth selection (FDI #11, #21, Other), Horizontal Incisal Overjet, Vertical Incisal Overlap, and Midline Deviation, with input boxes for millimeter measurements.   A clinical photograph showing a female patient in profile view placing her fingers on her left cheek and jawline, likely demonstrating a self-examination technique or anatomical location for palpation. A clinical photograph showing a female patient in profile view touching her left cheek with her hand, similar to the adjacent image but with a slightly different hand position, illustrating manual palpation of facial structures. - **RB** --- ### Opening Pattern (Supplemental; Select all that apply) - **Corrected Deviation** - **Uncorrected Deviation → Left** --- | Pattern | Description | Abbreviation | Image Description | |---------------|--------------------------------------------------|--------------|-----------------------------------------------| | **STRAIGHT** | | | | | **DEVIATION** | Mandible returns to centre position on opening | DD w/R | | | **DEFLECTION**| Continuous displacement of mandibular midline | DD w/o R | | #### Opening Pattern (Supplemental) - **Corrected Deviation:** Mandible returns to center position on opening (Abbreviation: DD w/R) - **Uncorrected Deviation (Deflection):** Continuous displacement of mandibular midline (Abbreviation: DD w/o R) - **Straight:** No deviation or deflection noted. **4. Opening Movements** A. Pain Free Opening: [ ] [ ] mm B. Maximum Unassisted Opening: [ ] [ ] mm C. Maximum Assisted Opening: [ ] [ ] mm D. Terminated? N Y <table> <thead> <tr> <th></th> <th colspan="3">RIGHT SIDE</th> <th colspan="3">LEFT SIDE</th> </tr> <tr> <th></th> <th>Pain</th> <th>Familiar Pain</th> <th>Familiar Headache</th> <th>Pain</th> <th>Familiar Pain</th> <th>Familiar Headache</th> </tr> </thead> <tbody> <tr> <td>Temporalis</td> <td>N Y</td> <td>N Y</td> <td>N Y</td> <td>N Y</td> <td>N Y</td> <td>N Y</td> </tr> <tr> <td>Masseter</td> <td>N Y</td> <td>N Y</td> <td></td> <td>N Y</td> <td>N Y</td> <td></td> </tr> <tr> <td>TMJ</td> <td>N Y</td> <td>N Y</td> <td></td> <td>N Y</td> <td>N Y</td> <td></td> </tr> <tr> <td>Other M Musc</td> <td>N Y</td> <td>N Y</td> <td></td> <td>N Y</td> <td>N Y</td> <td></td> </tr> <tr> <td>Non-mast</td> <td>N Y</td> <td>N Y</td> <td></td> <td>N Y</td> <td>N Y</td> <td></td> </tr> </tbody> </table>  #### Opening Movements Assessment - **A. Pain Free Opening:** [ ] mm - **B. Maximum Unassisted Opening:** [ ] mm - **C. Maximum Assisted Opening:** [ ] mm - **D. Terminated?** No / Yes | Structure | Right Pain | Right Familiar Pain | Right Familiar Headache | Left Pain | Left Familiar Pain | Left Familiar Headache | | :--- | :---: | :---: | :---: | :---: | :---: | :---: | | Temporalis | N / Y | N / Y | N / Y | N / Y | N / Y | N / Y | | Masseter | N / Y | N / Y | - | N / Y | N / Y | - | | TMJ | N / Y | N / Y | - | N / Y | N / Y | - | | Other M Musc | N / Y | N / Y | - | N / Y | N / Y | - | | Non-mast | N / Y | N / Y | - | N / Y | N / Y | - | Clinical assessment table titled 'Opening Movements'. The table is divided into sections for 'Pain Free Opening', 'Maximum Unassisted Opening', and 'Maximum Assisted Opening' on the left, with fields to record measurements in millimeters. The main body of the table compares symptoms ('Pain', 'Familiar Pain', 'Familiar Headache') across anatomical regions ('Temporalis', 'Masseter', 'TMJ', etc.) for both the 'RIGHT SIDE' and 'LEFT SIDE' of the patient. <details> <summary>1. Dentition</summary> | | **RIGHT SIDE** | **LEFT SIDE** | |------------------|-----------------------------------------------|-----------------------------------------------| | \\(x\\) Residual | | | | \\(\checkmark\\) Complete | 32-5-32 5-32 | 32-6-32 6-32 | | \\(\sim\\) Medical Pain | | ( / ) Rural Med | | | | | --- ### 2. Temporomandibular Joint \\(\checkmark\\) RIGHT SIDE | Normal \\(\checkmark\\) Left Side | Normal :---|:---|:--- \\( \sim \) Pain | ( / ) Pain | ( / ) Pain --- ### 3. Muscle Pain \\(\sim\\) Right Side | \\(\checkmark\\) Right Side \\( N \)\\( Y \) | ( / ) R/L ------------------|-----------------------------|----------------------------- * **Temporalis:** \\( \checkmark \) * **Masseter:** \\( \sim \) * **Other muscles:** \\( \sim \) \\( \sim \\) Left Side | \\( \sim \\) Left Side \\( N \)\\( Y \) | ( / ) L/R ------------------|-----------------------------|----------------------------- * **Temporalis:** \\( \sim \) * **Masseter:** \\( \sim \) * **Other muscles:** \\( \sim \) --- ### 4. Glutinous Posterior ####اید * ####اید ####یغ * ####یغ --- ### 5. Lateral and Protrusive Movements | | **RIGHT SIDE** | **LEFT SIDE** | |------------------|---------------------------------------------------------------|-----------------------------------------------------------------| | | **Pain** \\( N \)\\( Y \) |\* **Familiar Pain** \\( N \)\\( Y \) |\* **Familiar Headache** \\( N \)\\( Y \) | **Pain** \\( N \)\\( Y \) |\* **Familiar Pain** \\( N \)\\( Y \) |\* **Familiar Headache** \\( N \)\\( Y \) | | \\( \sim \) A. Right Lateral > [] two boxes mm - \\(< \\) | Temporalis | Masseter | TMJ | Other M Musc | Non-mast | Temporalis | Masseter | TMJ | Other M Musc | Non-mast | | \\( \sim \) B. Left Lateral > [] two boxes mm - \\(< \\) | Temporalis | Masseter | TMJ | Other M Musc | Non-mast | Temporalis | Masseter | TMJ | Other M Musc | Non-mast | | \\( \sim \) C. Protrusion > [] two boxes mm - \\(< \\) | Temporalis | Masseter | TMJ | Other M Musc | Non-mast | Temporalis | Masseter | TMJ | Other M Musc | Non-mast | | **O** If negative| | | --- ### MR. CELIAC **S.P.** CAPITALS | LOWER CHARACTERS #### SCALE 1. None 2. Mild 3. Moderate 4. Severe 5. Completely Cannot Stand #### SCALE 1. None 2. Mild 3. Modest 4. Strong 5. Strongly #### SCALE 1. None 2. Mild 3. Moderate 4. Severe 5. Very Severe </details>  #### Lateral and Protrusive Movements - **A. Right Lateral:** [ ] mm - **B. Left Lateral:** [ ] mm - **C. Protrusion:** [ ] mm **Pain Provocation Scale** 1. None 2. Mild 3. Moderate / Modest 4. Severe / Strong 5. Very Severe / Completely Cannot Stand A clinical assessment table titled '5. Lateral and Protrusive Movements' used for documenting TMJ function. The table is divided into two main sections: 'RIGHT SIDE' and 'LEFT SIDE'. Each section has columns for 'Pain', 'Familiar Pain', and 'Familiar Headache' with checkboxes (N/Y) to indicate presence or absence of symptoms. Rows are categorized by movement type (A. Right Lateral, B. Left Lateral, C. Protrusion) and anatomical structure (Temporalis, Masseter, TMJ, Other M Musc, Non-mast). On the far left, there are blank boxes for recording measurements in millimeters ('mm') for each movement, and a note at the bottom states 'O If negative'. The table includes pre-marked checkmarks in specific cells indicating recorded data.  A composite clinical figure showing four panels of mandibular movement measurements. Top-left panel labeled 'Right lateral movement' shows a ruler measuring the right side during lateral excursion. Top-right panel labeled 'Left lateral movement' shows measurement on the left side. Bottom two panels collectively labeled 'Protrusive movement' show anterior protrusion measurement with a ruler. All images depict close-ups of teeth and lips with an orthodontic ruler in place, demonstrating occlusal relationships during functional movements. ### 6. TMJ Noises During Open & Close Movements #### RIGHT TMJ | Examine | Open: N | Close: N | Open: Y | Close: Y | Patient | Pain w/ Click: N | Familiar Pain: Y | Pain w/ Click: Y | Familiar Pain: N | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Click | N | N | N | N | Y | N | Y | Y | N | | Crepitus| N | N | N | N | N | N | N | N | N | #### LEFT TMJ | Examine | Open: N | Close: N | Open: Y | Close: Y | Patient | Pain w/ Click: N | Familiar Pain: Y | Pain w/ Click: Y | Familiar Pain: N | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Click | N | N | N | N | Y | N | Y | Y | N | | Crepitus| N | N | N | N | N | N | N | N | N | ### 7. TMJ Noises During Lateral & Protrusive Movements #### RIGHT TMJ | Examine | Patient | Pain w/ Click: N | Familiar Pain: Y | Pain w/ Click: Y | Familiar Pain: N | | --- | --- | --- | --- | --- | --- | | Click | Y | N | Y | Y | N | | Crepitus| N | N | N | N | N | #### LEFT TMJ | Examine | Patient | Pain w/ Click: N | Familiar Pain: Y | Pain w/ Click: Y | Familiar Pain: N | | --- | --- | --- | --- | --- | --- | | Click | Y | N | Y | Y | N | | Crepitus| N | N | N | N | N |    #### TMJ Noises During Movements **Open & Close Movements** - **Right TMJ:** Click (Open/Close), Crepitus (Open/Close). Note if patient reports pain with click or if pain is familiar. - **Left TMJ:** Click (Open/Close), Crepitus (Open/Close). Note if patient reports pain with click or if pain is familiar. **Lateral & Protrusive Movements** - **Right TMJ:** Click (Yes/No), Crepitus (Yes/No). Note if pain with click is familiar. - **Left TMJ:** Click (Yes/No), Crepitus (Yes/No). Note if pain with click is familiar. Table titled '6. TMJ Noises During Open & Close Movements' divided into RIGHT TMJ and LEFT TMJ columns. It records findings for Click and Crepitus during Examine (Open/Close) and Patient movements, with Pain w/ Click and Familiar Pain outcomes. Specific cells are circled with N or Y to indicate presence of symptoms. Table titled '7. TMJ Noises During Lateral & Protrusive Movements' divided into RIGHT TMJ and LEFT TMJ columns. It records findings for Click and Crepitus during Examine and Patient movements, with Pain w/ Click and Familiar Pain outcomes. Specific cells are circled with N or Y to indicate presence of symptoms. Clinical photo series showing a female patient undergoing TMJ examination. Three panels show: 1) Examiner palpating the right TMJ area while patient looks forward; 2) Examiner palpating the left TMJ area while patient looks forward; 3) Examiner palpating the left TMJ area while patient performs a protrusive movement (mouth open). <table><tr><td colspan="10">8. Joint Locking</td></tr><tr><td colspan="6">RIGHT TMJ</td><td colspan="4">LEFT TMJ</td></tr><tr><td rowspan="3"></td><td colspan="2"></td><td colspan="2">Reduction</td><td></td><td colspan="2" rowspan="1"></td><td colspan="2">Reduction</td><td></td></tr><tr><td colspan="2">Locking</td><td>Patient</td><td>Examiner</td><td colspan="2">Locking</td><td>Patient</td><td>Examiner</td></tr><tr><td>While Opening</td><td>N Y</td><td>N</td><td>Y</td><td></td><td>DY</td><td>N</td><td>Y</td></tr><tr><td>Wide Open Position</td><td>N</td><td>Y</td><td>N</td><td>Y</td><td></td><td>N</td><td>Y</td><td>N</td><td>Y</td><td></td></tr></table>  #### Joint Locking Assessment - **Right TMJ Locking:** - While Opening: Yes/No - Wide Open Position: Yes/No - Reduction: Patient (Yes/No), Examiner (Yes/No) - **Left TMJ Locking:** - While Opening: Yes/No - Wide Open Position: Yes/No - Reduction: Patient (Yes/No), Examiner (Yes/No) A clinical assessment table titled '8. Joint Locking' comparing the Right TMJ and Left TMJ. The table is split into two main sections: RIGHT TMJ and LEFT TMJ. Each section contains columns for 'Locking', 'Reduction (Patient)', and 'Reduction (Examiner)'. Rows include 'While Opening' (highlighted in yellow) and 'Wide Open Position'. Cells contain circled N or Y indicators. ```html <table border='1'> <tr> <th>9. Muscle & TMJ Pain with Palpation</th> </tr> <tr> <th rowspan="2">RIGHT SIDE</th> <th colspan="4">LEFT SIDE</th> </tr> <tr> <th colspan="4">(1 kg)</th> <th colspan="4">(1 kg)</th> </tr> <tr> <th colspan="4">Familiar</th> <th colspan="4">Familiar</th> <th>Referred</th> </tr> <tr> <th rowspan="3"></th> <th>Pain</th> <td>Pain</td> <td>Headache</td> <td>Pain</td> <th>Pain</th> <td>Pain</td> <td>Headache</td> <td>Pain</td> </tr> <tr> <td>Temporalis (posterior)</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> </tr> <tr> <td>Temporalis (middle)</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> </tr> <tr> <td>Temporalis (anterior)</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> </tr> <tr> <th rowspan="3"></th> <td></td> <td> Familiar </td> <td> Familiar </td> <th>Referred</th> <td></td> <td> Familiar </td> <td> Familiar </td> <th>Referred</th> </tr> <tr> <td>Masseter (origin)</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td></td> <td></td> <td></td> <td></td> <td>N</td> <td>Y</td> </tr> <tr> <td>Masseter (body)</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td></td> <td></td> <td></td> <td></td> <td>N</td> <td>Y</td> </tr> <tr> <td>Masseter (insertion)</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td></td> <td></td> <td></td> <td></td> <td>N</td> <td>Y</td> </tr> <tr> <th>TMJ</th> <td colspan="2">Familiar</td> <th>Referred</th> <th colspan="2">Familiar</th> <th>Referred</th> </tr> <tr> <th></th> <td>Pain</td> <td>Pain</td> <td>Pain</td> <td colspan="2">Pain</td> <td>Pain</td> <td>Pain</td> </tr> <tr> <td>Lateral pole (0.5 kg)</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> </tr> <tr> <td>Around lateral pole (1 kg)</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> <td>N</td> <td>Y</td> </tr> </table> ```  #### Muscle & TMJ Pain with Palpation | Structure | Right Pain | Right Familiar Pain | Right Familiar Headache | Right Referred Pain | Left Pain | Left Familiar Pain | Left Familiar Headache | Left Referred Pain | | :--- | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | | Temporalis (post) | N/Y | N/Y | N/Y | N/Y | N/Y | N/Y | N/Y | N/Y | | Temporalis (mid) | N/Y | N/Y | N/Y | N/Y | N/Y | N/Y | N/Y | N/Y | | Temporalis (ant) | N/Y | N/Y | N/Y | N/Y | N/Y | N/Y | N/Y | N/Y | | Masseter (origin) | N/Y | N/Y | - | N/Y | N/Y | N/Y | - | N/Y | | Masseter (body) | N/Y | N/Y | - | N/Y | N/Y | N/Y | - | N/Y | | Masseter (ins) | N/Y | N/Y | - | N/Y | N/Y | N/Y | - | N/Y | | TMJ Lat. Pole (0.5kg) | N/Y | N/Y | - | N/Y | N/Y | N/Y | - | N/Y | | TMJ Around Pole (1kg) | N/Y | N/Y | - | N/Y | N/Y | N/Y | - | N/Y | A structured data table titled '9. Muscle & TMJ Pain with Palpation'. The table is divided into two main sections: 'RIGHT SIDE' and 'LEFT SIDE', each containing columns for '(1 kg)' force, 'Familiar Pain', 'Familiar Headache', and 'Referred Pain'. Rows list specific anatomical points including Temporalis (posterior, middle, anterior), Masseter (origin, body, insertion), and TMJ locations (Lateral pole, Around lateral pole). Each cell contains a binary choice marked by circled 'N' or 'Y', indicating the presence or absence of pain symptoms at that location. 10. Supplemental Muscle Pain with Palpation <1x>14 257109881701389.84</Ffont> 15. The Term "x-area" is used throughout the text to refer to a specific anatomical region. It is not necessary to translate the term, as it is already clear from the context of the medical texts. However, if clarification is needed, the "x-area" refers to the lateral pterygoid area. <1x>14 257107149463444.68</Ffont> 16. The term "y-area" is used throughout the text to refer to a specific anatomical region. It is not necessary to translate the term, as it is already clear from the context of the medical texts. However, if clarification is needed, the "y-area" refers to the temporalis tendon. <1x>14 257107149463444.68</Ffont> 17. The term "z-area" is used throughout the text to refer to a specific anatomical region. It is not necessary to translate the term, as it is already clear from the context of the medical texts. However, if clarification is needed, the "z-area" refers to the mandibular region. <1x>14 257107149463444.68</Ffont> 18. The term "w-area" is used throughout the text to refer to a specific anatomical region. It is not necessary to translate the term, as it is already clear from the context of the medical texts. However, if clarification is needed, the "w-area" refers to the submandibular region.    #### Supplemental Muscle Palpation Areas - **Lateral Pterygoid Area (x-area):** Specific anatomical region for supplemental examination. - **Temporalis Tendon (y-area):** Specific anatomical region for supplemental examination. - **Mandibular Region (z-area):** Specific anatomical region for supplemental examination. - **Submandibular Region (w-area):** Specific anatomical region for supplemental examination. A comparative table titled '10. Supplemental Muscle Pain with Palpation'. The table is split into two main columns: 'RIGHT SIDE' and 'LEFT SIDE'. Each side lists anatomical regions including Posterior mandibular region, Submandibular region, Lateral pterygoid area, and Temporalis tendon. For each region, there are columns for '(0.5 kg) Pain', 'Familiar Pain', and 'Referred Pain'. The cells contain circled checkmarks (Y) or crosses (N), indicating positive or negative findings for pain at specific locations. A clinical photograph showing the internal view of a patient's mouth with a gloved finger palpating the lateral aspect of the jaw. A caption below reads 'Lateral pterygoid area', corresponding to the anatomical region defined in the OCR text as the 'x-area'. A clinical photograph showing the internal view of a patient's mouth with a gloved finger palpating near the ear/jawline. A caption below reads 'Temporalis tendon', corresponding to the anatomical region defined in the OCR text as the 'y-area'. <table> <caption><b>Diagnostic Criteria for Temporomandibular Disorders (DC/TMD): Diagnostic Decision Tree</b><br><b>Pain-Related TMD and Headache</b></caption> <tr> <th valign=top><b>HISTORY</b><br>Start at each blue-outline box</th> <th rowspan=6 colspan=2><b>EXAMINATION</b><br><br><br></th> <th rowspan=6 colspan=2></th> </tr> <tr> <td colspan=2><div align="center"><b>Regional pain <font color="red">[SQ3]</font><br>AND<br>Pain modified by jaw movement, function, or parafunction <font color="red">[SQ4]</font><br><br><i>Yes</i></div></td> <td colspan=2><div align="center"><b>Diagnosis of Myalgia or Arthralgia</b></div></td> </tr> <tr> <td colspan=2><i>No</i></td> <td colspan=2><i>Yes</i></td> </tr> <tr> <td colspan=2><div align="center"><b>Headache of any type in temporal region <font color="red">[SQ5]</font><br>AND<br>Headache modified by jaw movement, function, or parafunction <font color="red">[SQ7]</font><br><br><i>Yes</i></div></td> <td colspan=2><i>No</i></td> </tr> <tr> <td colspan=2><div align="center"><b>Examiner confirmation of pain location <font color="red">[E1a]</font></div></td> <th colspan=2><b>EXAMINATION</b></th> </tr> <tr> <td colspan=2></td> <td colspan=2></td> </tr> </table> <table border=1 cellpadding=1 cellspacing=0> <tr> <td><b>Round</b><br><font color=blue>E1</font></td> <td colspan="3"> **Regional pain <font color="red">[SQ3]</font>** <br>AND <br> **Pain modified by jaw movement, function, or parafunction <font color="red">[SQ4]</font>** </td> <td rowspan=9> <b>Diagnosis of Myalgia or Arthralgia</b><br> <br> **Investigate other pain diagnoses** </td> </tr> <tr> <td colspan="3"><i>No</i></td> <td rowspan=9>v</td> </tr> <tr> <td><b>Square</b><br><font color="darkblue">SQ</font></td> <td colspan="3"> **Headache of any type in temporal region <font color="red">[SQ5]</font>** <br>AND <br> **Headache modified by jaw movement, function, or parafunction <font color="red">[SQ7]</font>** </td> </tr> <tr> <td><div align="center"><b>Examiner confirmation of pain location <font color="red">[E1a]</font></b></div></td> <td colspan="3"><i>Yes</i></td> </tr> <tr> <td><div align="center"><i>Yes = Mast muscles</i></div></td> <td colspan="2"><div align="center"><i><u>Investigate other Pain diagnoses</u></i></div></td> </tr> <tr> <td><div align="center"><i>Yes = TMJ</i></div></td> <td colspan="2"><div align="center"><i>No</i></div></td> </tr> <tr> <td rowspan=5><b>Diamond</b><br><font color="darkgreen">E</font></td> <td rowspan=5><div align="center"><b>Exam. Confirmation</b></div></td> <td colspan="2"> **Headache <b>any type</b> <br>in <b>temporal region</b> <font color="red">[SQ5]</font>** **AND**<br> **Headache modified by jaw movement, function, or parafunction <font color="red">[SQ7]</font>** </td> <td rowspan=3><div align="center"><b>Yes</b></div></td> </tr> <tr> <td colspan="3"><i>No</i></td> </tr> <tr> <td colspan="3"><i>Yes</i></td> </tr> <tr> <td colspan=2><i>No</i></td> <td colspan=2><div align="center"><b>Yes</b></div></td> </tr> <tr> <td colspan=2><i>No</i></td> <td colspan=2><div align="center"><i>Yes</i></div></td> </tr> <tr> <th colspan=1 rowspan=6><b>DIAGNOSIS</b></th> <th colspan=2 rowspan=6><div align="left"> (1) Familiar pain from:<br> jaw opening <font color="red">[muscle, E4]</font> OR<br> masticatory muscle palpation (2 secs) <font color="red">[muscle, E9]</font><br> AND<br> (2) Confirm location <font color="red">[E1a]</font><br> <br> <i>Yes</i> </div></th> <th colspan=3 rowspan=6><div align="left"> (1) Familiar pain from:<br> jaw opening <font color="red">[joint, E4]</font> OR<br> jaw horizontal movement <font color="red">[joint, E5]</font> OR<br> TMJ palpation <font color="red">[joint, E9]</font><br> AND<br> (2) Confirm location <font color="red">[E1a]</font><br> <br> <i>Yes</i> </div></th> </tr> <tr> <th colspan=1 rowspan=6><b>Exam. Confirmation</b></th> <th rowspan=5 colspan=4> <div align="left"> Examiner confirmation of headache in temporalis area <font color="red">[E1b]</font><br> <br> <i>Yes</i> </div> </th> </tr> <tr> <td rowspan=2 colspan=3><i>No</i></td> <td><i>No</i><br><i>No</i></td> </tr> <tr> <td colspan=2><div align="left"> Familiar headache from:<br> jaw opening OR excursive movement, OR temporalis muscle palpation<br> [temporalis, from E4, E5, OR E9] </div></td> </tr> <tr> <td colspan=2><i>No</i></td> <td colspan=2><div align="left"> **Headache not better accounted for by another headache diagnosis**<br> *[Symptom review]* </div></td> </tr> <tr> <td colspan=3><i>No</i></td> <td><i>N/A</i></td> </tr> <tr> <td colspan=3> <div align="left"> Familiar pain: MM palpation (5 secs) <font color="red">[muscle, E9]</font><br> <br> <i>Yes</i> </div> </td> <td rowspan=5></td> <td rowspan=5> <div align="left"> [i] familiar pain from: jaw opening <font color="red">[joint, E5]</font> OR<br> jow horizontal movement <font color="red">[joint, E5]</font> OR<br> TMJ palpation <font color="red">[joint, E9]</font><br> AND<br> (2) Confirm location <font color="red">[E1a]</font> </div> </td> </tr> <tr> <td rowspan=4><div align="center">Familiar pain: MM palpation 5 secs</div></td> <td colspan=3> <div align="left"> Extension of pain beyond muscle boundary <font color="red">[muscle, E9]</font><br> <br> <i>Yes</i> </div> </td> </tr> <tr> <td>Mast. muscles</td> <td colspan=2> <div align="left"> Pain extend beyond area of stimulation <font color="red">[muscle, E9]</font><br> <br> <i>Yes</i> </div> </td> </tr> <tr> <td> <div align="center">MM muscles</div><br> [To subtype myalgia] </td> <td> <div align="left">MyFacial pain with spreading</div> </td> <td> <div align="left"> Myofascial pain with referral </div> </td> </tr> <tr> <td><div align="center">Myalgia</div></td> <td><div align="center">Local myalgia</div></td> <td><div align="center">Myofascial pain with spreading</div></td> <td><div align="center">Arthralgia</div></td> </tr> <tr> <td colspan=2> <div align="center"> Note: 2 secs palpation is sufficient for myalgia; 5-secs is required for subtypes </div> </td> <td colspan=3> <div align="center"> Headache attributed to TMD </div></td> </tr> <tr> <td colspan=6> Version 7/4/2018 (text revision) </td> </tr> </table>  #### Pain-Related TMD and Headache Decision Tree **History Requirements:** - Regional pain [SQ3] AND pain modified by jaw function [SQ4]. - Headache in temporal region [SQ5] AND headache modified by jaw function [SQ7]. **Examination Confirmation:** - **Myalgia:** Familiar pain from jaw opening [E4] OR masticatory muscle palpation (2 seconds) [E9]. - **Arthralgia:** Familiar pain from jaw opening [E4], horizontal movement [E5], OR TMJ palpation [E9]. - **Headache Attributed to TMD:** Familiar headache from jaw opening, excursive movement, or temporalis palpation [E4, E5, E9]. **Myalgia Subtyping (5-second palpation):** - **Local Myalgia:** Pain localized to site of palpation. - **Myofascial Pain with Spreading:** Pain extends beyond the area of stimulation but remains within the muscle boundary. - **Myofascial Pain with Referral:** Pain extends beyond the boundary of the muscle. Diagnostic Decision Tree for Pain-Related TMD and Headache. The flowchart begins with 'HISTORY' criteria (Regional pain SQ3, Pain modified by jaw movement/function/parafunction SQ4) leading to 'EXAMINATION' confirmation of location E1a. It branches into two main diagnostic paths: Myalgia/Arthralgia (left side, involving familiar pain from jaw opening/masticatory muscle palpation or joint movement/TMJ palpation) and Headache (right side, involving headache in temporal region SQ5 modified by jaw movement/function/parafunction SQ7). The tree concludes with specific diagnoses including Myalgia, Local myalgia, Myofascial pain with spreading, Myofascial pain with referral, Arthralgia, and Headache attributed to TMD. A note at the bottom specifies that 2 seconds of palpation is sufficient for myalgia, while 5 seconds is required for subtypes. RB Diagnostic Criteria for Temporomandibular Disorders (DC/TMD): Diagnostic Decision Tree Intra-articular Joint Disorders Current TMJ noises by history [SQ8] OR Noise detected by patient during examination [E6 OR E7] Yes No By examiner: Opening & closing click [E6] OR [Opening or closing click [E6], AND Excursive or protrusive click [E7]] PINK OVAL: Investigate other diagnoses Current intermittent locking with limited opening [**SQ11**=yes & **SQ12**=no] Yes No If present in clinic: Maneuver required to open mouth [E8] else go to 'Yes' Yes No Disc displacement with reduction Disc displacement with reduction, with intermittent locking Disc displacement without reduction, with limited opening Green OVAL: Confirm by MRI when indicated Prior jaw locking in closed position [SQ9] **AND** Interference in mastication [SQ10] No Yes MAO ≥ 40mm (including overbite) [E4C] No Yes Disc displacement without reduction without limited opening Disc displacement without reduction, with limited opening Green OVAL: Confirm by MRI when indicated Degenerative Joint Disorder Current TMJ noises by history [SQ8] OR Noise detected by patient during examination [E6 OR E7] Yes No Crepitus detected by examiner [E6 OR E7] Yes No OVAL: Degenerative joint disease Light Blue OVAL: Disc displacement without reduction without limited opening Light Blue OVAL: Disc displacement without reduction, with limited opening Green OVAL: Confirm by MRI when indicated PINK OVAL: Investigate other diagnoses Subluxation History of open lock [SQ13] **AND** History of maneuver to close the mouth [SQ14] Yes Lock in open position if clinically present [E8] Yes OVAL: Subluxation  #### Intra-articular and Degenerative Disorders Decision Tree **Disc Displacement with Reduction (DDwR):** - History of TMJ noises [SQ8] OR noise detected during exam [E6, E7]. - Examiner detects opening/closing click. **Disc Displacement without Reduction (DDwoR):** - **With Limited Opening:** History of locking [SQ11], MAO < 40mm [E4C]. - **Without Limited Opening:** History of prior locking [SQ9], interference in mastication [SQ10], MAO ≥ 40mm. **Degenerative Joint Disease (DJD):** - History of TMJ noises [SQ8] OR noise detected during exam [E6, E7]. - Crepitus detected by examiner [E6, E7]. **Subluxation:** - History of open lock [SQ13] AND history of maneuver to close mouth [SQ14]. - Lock in open position clinically present [E8]. A complex flowchart titled 'Diagnostic Criteria for Temporomandibular Disorders (DC/TMD): Diagnostic Decision Tree'. The diagram is divided into three main vertical columns: 'Intra-articular Joint Disorders', 'Degenerative Joint Disorder', and 'Subluxation'. It uses a hierarchical structure of rectangular decision boxes containing text queries (e.g., 'Current TMJ noises by history [SQ8]', 'Prior jaw locking in closed position [SQ9]') connected by arrows labeled 'Yes' or 'No'. These paths lead to oval-shaped nodes representing clinical diagnoses such as 'Disc displacement with reduction' (light blue), 'Degenerative joint disease' (light blue), and 'Subluxation' (light blue). Pink ovals indicate steps to 'Investigate other diagnoses', while green ovals at the bottom indicate imaging confirmations ('Confirm by MRI when indicated', 'Confirm by CT when indicated'). A sidebar on the left categorizes the workflow into 'HISTORY & EXAMINATION', 'CLINICAL DIAGNOSIS', and 'IMAGING'. RB **DC/TMD** **EXAMINATION** **VIDEO** **University at Buffalo School of Dental Medicine** **DC/TMD Examination Protocol** Yoly Gonzalez, DDS, MS, MPH Jason Chwirut, MS Thomas List, DDS, PhD Richard Orhbach, DDS, PhD #### DC/TMD Examination Protocol Contributors - Yoly Gonzalez, DDS, MS, MPH - Jason Chwirut, MS - Thomas List, DDS, PhD - Richard Orhbach, DDS, PhD - University at Buffalo School of Dental Medicine BRIEF DC/TMD DurhamJ, Ohrbach R, Baad-Hansen L, et al. Constructing the brief diagnostic criteria for temporomandibular disorders (bDC/TMD) for field testing. J Oral Rehabil. 2023; 00: 1-10. Durham J, Ohrbach R, Baad-Hansen L, et al. Constructing the brief diagnostic criteria for temporomandibular disorders (bDC/TMD) for field testing. J Oral Rehabil. 2023; 00: 1-10. # BRIEF DC/TMD 1. The bDC/TMD Axis 1 and Axis 2 should take no more than 10 minutes of provider time to complete in its entirety in clinic, and the structure of the bDC/TMD should optimise and maximise the patient's use of self-report instrumentation; 2. The bDC/TMD should produce Axis 1 grouping diagnoses or combinations thereof with clinical utility rather than down to the level of all 12 of the most frequently presenting sub-types of TMDs. These groupings are painful TMDs (inclusive of myalgia, arthralgia and headache attributed to TMD) or other common joint-related TMDs with implications for function (inclusive of degenerative joint disease, subluxation, acute closed lock and a collapsed category of other disc based TMDs). Axis 2 should focus on an ultra-brief screen to demonstrate yellow or red flags in psychosocial status; 3. Training for clinicians in the use of the bDC/TMD will be provided via distance learning such as through video training material. The training component will require additional resources to effectively implement across languages and settings, but it is deemed an immediately achievable goal that can be empirically tested later. DurhamJ, Ohrbach R, Baad-Hansen L, et al. Constructing the brief diagnostic criteria for temporomandibular disorders (bDC/TMD) for field testing. J Oral Rehabil. 2023; 00: 1-10. #### bDC/TMD Objectives and Structure 1. **Efficiency:** Axis I and Axis II should take no more than 10 minutes of provider time, maximizing patient self-report instrumentation. 2. **Diagnostic Groupings:** Focuses on broad clinical utility groupings: - **Painful TMDs:** Myalgia, arthralgia, and headache attributed to TMD. - **Joint-related TMDs:** Degenerative joint disease, subluxation, acute closed lock, and disc-based TMDs. - **Axis II:** Ultra-brief screen for psychosocial yellow or red flags. 3. **Training:** Provided via distance learning and video materials. <table> <tr> <th title="DC/TMD examination item number">DC/TMD examination item number<sup>a</sup></th> <th>Summary of examination item</th> <th>Delphi consensus</th> <th>Notes</th> </tr> <tr> <td>E1a</td> <td>Patient's identification of areas of pain. Areas of interest are demonstrated by light touch by examiner as: Temporalis, Masseter, TMJ, other masticatory muscles, non-masticatory structures</td> <td>Retain and revise</td> <td>Remove other masticatory muscles and non-masticatory structures as not incorporated within new bDC/TMD diagnostic decision tree producing broad grouping diagnoses</td> </tr> <tr> <td>E1b</td> <td>Anatomical area affected by headache</td> <td>Remove</td> <td>Not required for new bDC/TMD diagnostic decision tree</td> </tr> <tr> <td>E2</td> <td>Incisal relationship</td> <td>Remove</td> <td>Remove as additional detail unrequired for broad grouping diagnoses in new bDC/TMD diagnostic decision tree</td> </tr> <tr> <td>E3</td> <td>Opening pattern</td> <td>Remove</td> <td>Already considered 'supplemental' in DC/TMD largely due to poor reliability of this assessment; not used by its diagnostic decision tree</td> </tr> <tr> <td>E4</td> <td>Opening movements</td> <td>Retain and revise</td> <td>Simplify to only pain-free and maximum unassisted opening given (a) this differentiates between painful and non-painful TMDs and (b) helps with defining acute closed lock (disc displacement without reduction with limited opening). Reduce to 3 examination steps for a combined examination of E4, E6, E8 with 1 out of 3 movements being a positive finding with no further movement required once positive identified</td> </tr> <tr> <td>E5</td> <td>Lateral movements</td> <td>Remove</td> <td>Have low reliability, contribute little to diagnosis, and difficult for patients to reproduce.</td> </tr> <tr> <td>E6</td> <td>Joint noises on opening and closing</td> <td>Retain and revise</td> <td>Adjusted and shortened examination steps, as stated under E4</td> </tr> <tr> <td>E7</td> <td>Joint noises on lateral and protrusive movements</td> <td>Remove</td> <td>Low yield of positive results from these movements.</td> </tr> <tr> <td>E8</td> <td>Joint locking</td> <td>Retain and revise</td> <td>Adjusted and shortened examination steps, as stated under E4</td> </tr> <tr> <td>E9</td> <td>Muscle and TMJ pain with palpation</td> <td>Retain and revise</td> <td>Remove reporting of palpation results from specified anatomical sub-sections of muscles (e.g. origin, body and insertion of masseter) as unnecessary level of detail for bDC/TMD diagnostic decision tree. The protocol will specify to focus examination on anterior temporalis and body of masseter as initial sites to examine with palpation, and to extend beyond those areas as needed, but form only requires findings at the muscle level. <br/>(Remove supplemental muscles from examination as non-contributory to diagnostic decision tree currently in DC/TMD and therefore unnecessary for bDC/TMD)</td> </tr> <tr> <td colspan="4"><sup>a</sup>Reference period whenever given in a question is in the last 30 days. It is however important to note that whilst the 30 days period is useful and appropriate for most patients, sometimes a complaint may require that the reference frame be modified.</td> </tr> </table>  #### Summary of Brief Examination Items - **E1a (Pain Identification):** Retained and revised. Focuses on Temporalis, Masseter, and TMJ. Removed "other masticatory muscles" and "non-masticatory structures." - **E1b (Headache Area) & E2 (Incisal Relationship):** Removed as unnecessary for broad grouping diagnoses. - **E3 (Opening Pattern):** Removed due to poor reliability. - **E4 (Opening Movements):** Retained and revised. Simplified to pain-free and maximum unassisted opening. Combined with E6 and E8. - **E5 (Lateral Movements) & E7 (Excursive Noises):** Removed due to low reliability and low diagnostic yield. - **E6 (Joint Noises) & E8 (Joint Locking):** Retained and revised. Integrated into a simplified 3-step movement examination. - **E9 (Palpation):** Retained and revised. Reporting simplified to muscle level (Temporalis/Masseter) rather than sub-sections (origin/body/insertion). Focuses on anterior temporalis and masseter body. Table 3 showing 'Original DC/TMD Axis 1 examination items and agreed reduction of these items by Delphi panel.' Columns include: DC/TMD examination item number (E1a-E9), Summary of examination item, Delphi consensus (Retain/Remove), and Notes detailing the rationale for changes.  A structured table titled '1a. Location of Pain: Last 30 days (Select all that apply)' with two main columns labeled 'RIGHT PAIN' and 'LEFT PAIN'. Each column contains radio button options for pain locations including None, Temporalis, Masseter, Other m muscles, TMJ, and Non-mast structures. ### **Opening Movements** | | Pain Free Opening | RIGHT SIDE | | | LEFT SIDE | | | | :--- | :--- | :---: | :---: | :---: | :---: | :---: | :---: | | **A.** | [ bx | bx ] mm | **Pain** | **Familiar Pain** | **Familiar Headache** | **Pain** | **Familiar Pain** | **Familiar Headache** | | | | N | Y | N | Y | N | Y | | **B. Maximum Unassisted Opening** | [ bx | bx ] mm | **Right Side** | | **Left Side** | | | | | | | **Temporalis** Temporalis | N | Y | N | Y | N | Y | | | | Masseter | N | Y | N | Y | | | | | | **TMJ** | N | Y | N | Y | | | | | | Other M Musc | N | Y | N | Y | | | | | | Non-mast | N | Y | N | Y | | | | **C. Maximum Assisted Opening** | [ bx | bx ] mm | **Temporalis** Temporalis | N | Y | N | Y | N | Y | | | | Masseter | N | Y | N | Y | | | | | | **TMJ** | N | Y | N | Y | | | | | | Other M Musc | N | Y | N | Y | | | | | | Non-mast | N | Y | N | Y | | | | **D. Terminated?** | **N** **Y** | | | | | | |  #### Brief Opening Movements Assessment - **A. Pain Free Opening:** [ ] mm - **B. Maximum Unassisted Opening:** [ ] mm - **C. Maximum Assisted Opening:** [ ] mm - **D. Terminated?** No / Yes **Provocation Findings:** - **Temporalis:** Pain, Familiar Pain, Familiar Headache (Right/Left) - **Masseter:** Pain, Familiar Pain (Right/Left) - **TMJ:** Pain, Familiar Pain (Right/Left) A clinical assessment table titled 'Opening Movements' (Section 4). The table is divided into two main columns: 'RIGHT SIDE' and 'LEFT SIDE'. It assesses four categories of jaw movement (A. Pain Free Opening, B. Maximum Unassisted Opening, C. Maximum Assisted Opening, D. Terminated?). For each category, there are rows for anatomical structures (Temporalis, Masseter, TMJ, Other M Musc, Non-mast) and columns for symptoms (Pain, Familiar Pain, Familiar Headache). Each cell contains a circle with 'N' or 'Y' to indicate the presence or absence of findings. 6. TMJ Noises During Open & Close Movements * **RIGHT TMJ** * **Examiner:** * Open: N, Y * Close: N, Y * **Patient:** N, Y * **Pain w/ Click:** N, Y * **Familiar Pain:** N, Y * **Row 1:** Click | N, Y | N, Y * **Row 2:** Crepitus | N, Y | N, Y * *(Text indicates reduction to N, Y with 1 out of 3 movements positive)* * **LEFT TMJ** * **Examiner:** * Open: N, Y * Close: N, Y * **Patient:** N, Y * **Pain w/ Click:** N, Y * **Familiar Pain:** N, Y * **Row 1:** Click | N, Y | N, Y * **Row 2:** Crepitus | N, Y | N, Y * *(Text indicates reduction to N, Y with 1 out of 3 movements positive)* 8. Joint Locking * **RIGHT TMJ** * **Reduction:** * Patient: N, Y * Examiner: N, Y * **Row 1:** While Opening | N, Y * **Row 2:** Wide Open Position | N, Y * **LEFT TMJ** * **Reduction:** * Patient: N, Y * Examiner: N, Y * **Row 1:** While Opening | N, Y * **Row 2:** Wide Open Position | N, Y Reduce to 3 examination steps for a combined examination of E4, E6, E8 with **1 out of 3 movements being a positive finding** with no further movement required once positive identified #### Brief TMJ Noises and Locking **TMJ Noises (Open/Close)** - Examiner detects Click or Crepitus. - Patient reports noise. - Note if pain with click is familiar. **Joint Locking** - **Reduction:** Note if achieved by patient or examiner. - **Locking types:** While opening or in wide open position. **Simplified Protocol:** Combined examination of E4, E6, and E8 using 3 steps; if any one movement is positive, no further movement is required. **9. Muscle & TMJ Pain with Palpation** **RIGHT SIDE** | (1 kg) | Pain | Familiar Pain | Familiar Headache | Referred Pain | | :--- | :---: | :---: | :---: | :---: | | Temporalis (posterior) | N | Y | N | Y | | Temporalis (middle) | N | Y | N | Y | | Temporalis (anterior) | N | Y | N | Y | | Masseter (origin) | N | Y | N | Y | N | Y | | Masseter (body) | N | Y | N | Y | N | Y | | Masseter (insertion) | N | Y | N | Y | N | Y | | **TMJ** | **Pain** | **Familiar Pain** | **Referred Pain** | | | | Lateral pole (0.5 kg) | N | Y | N | Y | N | Y | | Around lateral pole (1 kg) | N | Y | N | Y | N | Y | **LEFT SIDE** | (1 kg) | Pain | Familiar Pain | Familiar Headache | Referred Pain | | :--- | :---: | :---: | :---: | :---: | | Temporalis (posterior) | N | Y | N | Y | N | Y | | Temporalis (middle) | N | Y | N | Y | N | Y | | Temporalis (anterior) | N | Y | N | Y | N | Y | | Masseter (origin) | N | Y | N | Y | N | Y | | Masseter (body) | N | Y | N | Y | N | Y | | Masseter (insertion) | N | Y | N | Y | N | Y | | | **Pain** | **Familiar Pain** | **Referred Pain** | | | :--- | :---: | :---: | :---: | :---: | | Lateral pole (0.5 kg) | N | Y | N | Y | N | Y | | Around lateral pole (1 kg) | N | Y | N | Y | N | Y | Bolded text: Remove reporting of palpation results from specified anatomical sub- sections of muscles (e.g. origin, body and insertion of masseter) as unnecessary level of detail for bDC/TMD diagnostic decision tree. The protocol will specify to focus examination on anterior temporalis and body of masseter as initial sites to examine with palpation, and to extend beyond those areas as needed, but form only requires findings at the muscle level. Remove supplemental muscles from examination as non- contributory to diagnostic decision tree currently in DC/TMD and therefore unnecessary for bDC/TMD  #### Brief Muscle & TMJ Palpation - **Palpation Sites:** Temporalis (anterior, middle, posterior) and Masseter (origin, body, insertion). - **TMJ Sites:** Lateral pole (0.5 kg) and around lateral pole (1 kg). - **Data Points:** Pain, Familiar Pain, Familiar Headache, and Referred Pain. **Protocol Note:** For the bDC/TMD, reporting is simplified to the muscle level. Examiners focus on the anterior temporalis and masseter body. Supplemental muscles are removed from this brief protocol. A detailed clinical data table titled '9. Muscle & TMJ Pain with Palpation'. The table is split into two main columns: 'RIGHT SIDE' and 'LEFT SIDE'. It lists anatomical regions (Temporalis posterior/middle/anterior, Masseter origin/body/insertion, TMJ Lateral pole/Around lateral pole) and their corresponding findings under categories like '(1 kg)', 'Pain', 'Familiar Pain', 'Familiar Headache', and 'Referred Pain'. Each cell contains a circled 'N' or 'Y' indicating the presence or absence of symptoms. **Brief Diagnostic Criteria for Temporomandibular Disorders (bDC/TMD): Diagnostic Decision Tree** ### Painful TMDs: Myalgia, arthralgia and headache attributed to TMD ```mermaid graph TD subgraph HISTORY A[Regional pain SQ1 or Headache SQ5 <br/>AND<br/>Pain or headache modified by jaw movement, function,<br/>or parafunction SQ4 or SQ7] end subgraph EXAMINATION B[Examiner confirmation of pain location E1 <br/>Masticatory muscles, or TMJ] C["Familiar pain or headache from<br/>Jaw opening E2<br/>OR<br/>masticatory muscle palpation (2 secs) E4<br/>OR<br/>TMJ palpation E4"] D[Headache not better <br/>accounted for by another<br/>headache diagnosis<br/>Symptom review] end subgraph DIAGNOSIS E([<b>Painful TMDs</b><br/>Myalgia Familiar pain on muscle palpation<br/>Arthralgia Familiar pain on joint palpation or movement<br/>Headache attributable to TMD<br/>Familiar pain on temporalis palpation or jaw movement]) end F([Investigate other<br/>Pain diagnoses]) A -- Yes --> B A -- No --> F B -- Yes --> C B -- No --> F C -- Yes --> E C -- No --> F C -- If headache is a symptom --> D D -- Yes --> E D -- No --> F ```  #### Painful TMDs Decision Tree 1. **History:** Regional pain [SQ1] or Headache [SQ5] AND modification by jaw function [SQ4/SQ7]. 2. **Examination:** - Confirm pain location [E1] in masticatory muscles or TMJ. - Identify familiar pain/headache from jaw opening [E2], muscle palpation [E4], or TMJ palpation [E4]. 3. **Diagnosis:** - **Myalgia:** Familiar pain on muscle palpation. - **Arthralgia:** Familiar pain on joint palpation or movement. - **Headache attributable to TMD:** Familiar pain on temporalis palpation or jaw movement (if not better accounted for by another diagnosis). Flowchart titled 'Brief Diagnostic Criteria for Temporomandibular Disorders (bDC/TMD): Diagnostic Decision Tree' focusing on 'Painful TMDs: Myalgia, arthralgia and headache attributed to TMD'. The diagram is structured into three vertical sections labeled HISTORY, EXAMINATION, and DIAGNOSIS. It features decision nodes including 'Regional pain [SQ1] or Headache [SQ5]', 'Examiner confirmation of pain location [E1]', and 'Familiar pain or headache from Jaw opening [E2] OR masticatory muscle palpation (2 secs) [E4] OR TMJ palpation [E4]'. Arrows direct the flow based on Yes/No answers, leading to outcomes such as 'Investigate other Pain diagnoses' or the final diagnosis node 'Painful TMDs', which lists specific criteria for Myalgia, Arthralgia, and Headache attributable to TMD. A version stamp 'Version 1 6th June 2023' appears at the bottom right. ^1^Imaging is not considered at this stage of evaluation, diagnosis, and initial treatment^  Imaging is not considered at this stage of evaluation, diagnosis, and initial treatment. A comprehensive diagnostic decision tree titled 'Brief Diagnostic Criteria for Temporomandibular Disorders (bDC/TMD): Diagnostic Decision Tree' and subtitled 'Common joint-related TMDs with implications for function'. The diagram is structured into three vertical sections: HISTORY, EXAMINATION, and CLINICAL DIAGNOSIS. It features multiple flowchart paths starting from blue boxes labeled 'START', branching through decision points involving symptoms like jaw locking, crepitus, and mouth opening limits, leading to outcomes such as 'Degenerative joint disease', 'Acute closed lock', or 'Subluxation'. Key labels include [SQ8], [E3], MUO < 35mm, and references to imaging exclusion at the bottom. # REMEMBER YOUR AXIS-II REMEMBER YOUR AXIS-II ## 3 Axis II Screening Tools: • Pain Drawing (pain location) • GCPS (pain intensity and disability) • PHQ-4 (psychological distress) ### GRADED CHRONIC PAIN SCALE - 30 DAYS, PAIN MANIKAN, PATIENT HEALTH QUESTIONNAIRE #### Self-report Section B – Graded Chronic Pain Scale – 30 days **1. How would you rate your facial pain RIGHT NOW?** | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |---|---|---|---|---|---|---|---|---|---|---| | No pain | | | | | | | | | | Pain as bad as could be | **2. In the LAST 30 DAYS, how would you rate your WORST facial pain?** | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |---|---|---|---|---|---|---|---|---|---|---| | No pain | | | | | | | | | | Pain as bad as could be | **3. In the LAST 30 DAYS, ON AVERAGE, how would you rate your facial pain?** | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |---|---|---|---|---|---|---|---|---|---|---| | No pain | | | | | | | | | | Pain as bad as could be | **[(Q1+Q2+Q3)/3]x10 = CPI =** **4. In the LAST 30 DAYS, how much has facial pain interfered with your DAILY ACTIVITIES?** | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |---|---|---|---|---|---|---|---|---|---|---| | No interference | | | | | | | | | | Unable to carry on any activities | **5. In the LAST 30 DAYS, how much has facial pain interfered with your RECREATIONAL, SOCIAL AND FAMILY ACTIVITIES?** | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |---|---|---|---|---|---|---|---|---|---|---| | No interference | | | | | | | | | | Unable to carry on any activities | **6. In the LAST 30 DAYS, how much has facial pain interfered with your ABILITY TO WORK, including housework?** | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |---|---|---|---|---|---|---|---|---|---|---| | No interference | | | | | | | | | | Unable to carry on any activities | **[(Q4+Q5+Q6)/3]x10 = Disability =** #### Pain Drawing Indicate the location of ALL of your different pains by shading in the area, using the diagrams that are most relevant. If there is an exact spot where the pain is located, indicate with a solid dot (•). If your pain moves from one location to another, use arrows to show the path. Mouth and teeth Right face Left face #### Patient Health Questionnaire - 4 Over the last 2 weeks, how often have you been bothered by the following problems? Please place a check mark in the box to indicate your answer. | | Not at all 0 | Several days 1 | More than half the days 2 | Nearly every day 3 | |---|---|---|---|---| | 1. Feeling nervous, anxious or on edge | ☐ | ☐ | ☐ | ☐ | | 2. Not being able to stop or control worrying | ☐ | ☐ | ☐ | ☐ | | 3. Little interest or pleasure in doing things | ☐ | ☐ | ☐ | ☐ | | 4. Feeling down, depressed, or hopeless | ☐ | ☐ | ☐ | ☐ | **TOTAL SCORE =** If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? | Not difficult at all | Somewhat difficult | Very difficult | Extremely difficult | |---|---|---|---| | ☐ | ☐ | ☐ | ☐ | #### Scoring | Scoring | 0 | 10 | 20 | 30 | 40 | 50 | 60 | 70 | 80 | 90 | 100 | |---|---|---|---|---|---|---|---|---|---|---|---| | Interpretation of pain intensity (CPI) and interference | None | Mild | | | | | Moderate | | | Severe | |     #### Axis II Screening Tools - **Pain Drawing:** Identification of pain location. - **Graded Chronic Pain Scale (GCPS):** Assessment of pain intensity and disability over the last 30 days. - **PHQ-4:** Screening for psychological distress (anxiety and depression). #### Graded Chronic Pain Scale (30 Days) - **Pain Intensity (CPI):** Average of "Right Now," "Worst," and "Average" pain ratings (0-10 scale). - **Disability Score:** Average of interference with "Daily Activities," "Recreational/Social Activities," and "Ability to Work" (0-10 scale). #### Patient Health Questionnaire - 4 (PHQ-4) - **Anxiety:** Feeling nervous/anxious; unable to control worrying. - **Depression:** Little interest/pleasure; feeling down/depressed. - **Scoring:** 0 (Not at all) to 3 (Nearly every day). Total score indicates level of distress. #### Scoring Interpretation - **0-10:** None - **10-40:** Mild - **40-70:** Moderate - **70-100:** Severe Table for Self-report Section B – Graded Chronic Pain Scale – 30 days. Contains six questions (Q1-Q6) asking patients to rate current/worst/average pain and interference with daily activities on a scale of 0-10. Includes calculation formulas for CPI and Disability. Scoring chart interpreting the sum of Q1-Q3 (CPI) and Q4-Q6 (Disability). Color-coded bars indicate severity levels: None (Green), Mild (Yellow), Moderate (Orange), Severe (Red). Pain Drawing diagrams showing human body outlines (front/back view) and head profiles (left/right face). Instructions indicate shading areas or using dots/arrows to mark pain locations. Patient Health Questionnaire - 4 (PHQ-4). Table listing four psychological distress symptoms with frequency options (Not at all to Nearly every day). Includes a Total Score field and an additional table assessing difficulty level of problems. # TAKE HOME MESSAGE * Temporomandibular Disorders (TMD) is a collective term * TMD is caused by the combination of genetics, sensory processing, psychological and behavioural factors * History of the pain patient develops 80% of the diagnosis * DC/TMD is a reliable and standardized protocol for diagnosing TMD in specialist settings * Brief DC/TMD has been developed to increase utility and expedite diagnosis in TMDs in non specialist general dental practice #### Key Concepts of Temporomandibular Disorders - Temporomandibular Disorders (TMD) is a collective term. - TMD is caused by the combination of genetics, sensory processing, psychological, and behavioural factors. #### Diagnostic Protocols and Clinical Practice - History of the pain patient develops 80% of the diagnosis. - DC/TMD is a reliable and standardized protocol for diagnosing TMD in specialist settings. - Brief DC/TMD has been developed to increase utility and expedite diagnosis in TMDs in non-specialist general dental practice. # THANK YOU!! **Ramesh Balasubramaniam OAM** DENT5310 **Orofacial Pain and Dental Sleep Medicine Module** 16th April 2026 The University of Western Australia Perth Oral Medicine & Dental Sleep Centre Perth Children’s Hospital PERIOGOLD® Helps Improve Oral Health OMAA Oral Medicine Academy of Australasia DSSWA ADA Australian Dental Association Australian Sleep Association [^1]: Original PDF page 1: [[L28 TMD.pdf#page=1|L28 TMD, p.1]] [^2]: Original PDF page 2: [[L28 TMD.pdf#page=2|L28 TMD, p.2]] [^3]: Original PDF page 3: [[L28 TMD.pdf#page=3|L28 TMD, p.3]] [^4]: Original PDF page 4: [[L28 TMD.pdf#page=4|L28 TMD, p.4]] [^5]: Original PDF page 5: [[L28 TMD.pdf#page=5|L28 TMD, p.5]] [^6]: Original PDF page 6: [[L28 TMD.pdf#page=6|L28 TMD, p.6]] [^7]: Original PDF page 7: [[L28 TMD.pdf#page=7|L28 TMD, p.7]] [^8]: Original PDF page 8: [[L28 TMD.pdf#page=8|L28 TMD, p.8]] [^9]: Original PDF page 9: [[L28 TMD.pdf#page=9|L28 TMD, p.9]] [^10]: Original PDF page 10: [[L28 TMD.pdf#page=10|L28 TMD, p.10]] [^11]: Original PDF page 11: [[L28 TMD.pdf#page=11|L28 TMD, p.11]] [^12]: Original PDF page 12: [[L28 TMD.pdf#page=12|L28 TMD, p.12]] [^13]: Original PDF page 13: [[L28 TMD.pdf#page=13|L28 TMD, p.13]] [^14]: Original PDF page 14: [[L28 TMD.pdf#page=14|L28 TMD, p.14]] [^15]: Original PDF page 15: [[L28 TMD.pdf#page=15|L28 TMD, p.15]] [^16]: Original PDF page 16: [[L28 TMD.pdf#page=16|L28 TMD, p.16]] [^17]: Original PDF page 17: [[L28 TMD.pdf#page=17|L28 TMD, p.17]] [^18]: Original PDF page 18: [[L28 TMD.pdf#page=18|L28 TMD, p.18]] [^19]: Original PDF page 19: [[L28 TMD.pdf#page=19|L28 TMD, p.19]] [^20]: Original PDF page 20: [[L28 TMD.pdf#page=20|L28 TMD, p.20]] [^21]: Original PDF page 21: [[L28 TMD.pdf#page=21|L28 TMD, p.21]] [^22]: Original PDF page 22: [[L28 TMD.pdf#page=22|L28 TMD, p.22]] [^23]: Original PDF page 23: [[L28 TMD.pdf#page=23|L28 TMD, p.23]] [^24]: Original PDF page 24: [[L28 TMD.pdf#page=24|L28 TMD, p.24]] [^25]: Original PDF page 25: [[L28 TMD.pdf#page=25|L28 TMD, p.25]] [^26]: Original PDF page 26: [[L28 TMD.pdf#page=26|L28 TMD, p.26]] [^27]: Original PDF page 27: [[L28 TMD.pdf#page=27|L28 TMD, p.27]] [^28]: Original PDF page 28: [[L28 TMD.pdf#page=28|L28 TMD, p.28]] [^29]: Original PDF page 29: [[L28 TMD.pdf#page=29|L28 TMD, p.29]] [^30]: Original PDF page 30: [[L28 TMD.pdf#page=30|L28 TMD, p.30]] [^31]: Original PDF page 31: [[L28 TMD.pdf#page=31|L28 TMD, p.31]] [^32]: Original PDF page 32: [[L28 TMD.pdf#page=32|L28 TMD, p.32]] [^33]: Original PDF page 33: [[L28 TMD.pdf#page=33|L28 TMD, p.33]] [^34]: Original PDF page 34: [[L28 TMD.pdf#page=34|L28 TMD, p.34]] [^35]: Original PDF page 35: [[L28 TMD.pdf#page=35|L28 TMD, p.35]] [^36]: Original PDF page 36: [[L28 TMD.pdf#page=36|L28 TMD, p.36]] [^37]: Original PDF page 37: [[L28 TMD.pdf#page=37|L28 TMD, p.37]] [^38]: Original PDF page 38: [[L28 TMD.pdf#page=38|L28 TMD, p.38]] [^39]: Original PDF page 39: [[L28 TMD.pdf#page=39|L28 TMD, p.39]] [^40]: Original PDF page 40: [[L28 TMD.pdf#page=40|L28 TMD, p.40]] [^41]: Original PDF page 41: [[L28 TMD.pdf#page=41|L28 TMD, p.41]] [^42]: Original PDF page 42: [[L28 TMD.pdf#page=42|L28 TMD, p.42]] [^43]: Original PDF page 43: [[L28 TMD.pdf#page=43|L28 TMD, p.43]] [^44]: Original PDF page 44: [[L28 TMD.pdf#page=44|L28 TMD, p.44]] [^45]: Original PDF page 45: [[L28 TMD.pdf#page=45|L28 TMD, p.45]] [^46]: Original PDF page 46: [[L28 TMD.pdf#page=46|L28 TMD, p.46]] [^47]: Original PDF page 47: [[L28 TMD.pdf#page=47|L28 TMD, p.47]] [^48]: Original PDF page 48: [[L28 TMD.pdf#page=48|L28 TMD, p.48]] [^49]: Original PDF page 49: [[L28 TMD.pdf#page=49|L28 TMD, p.49]] [^50]: Original PDF page 50: [[L28 TMD.pdf#page=50|L28 TMD, p.50]] [^51]: Original PDF page 51: [[L28 TMD.pdf#page=51|L28 TMD, p.51]] [^52]: Original PDF page 52: [[L28 TMD.pdf#page=52|L28 TMD, p.52]] [^53]: Original PDF page 53: [[L28 TMD.pdf#page=53|L28 TMD, p.53]] [^54]: Original PDF page 54: [[L28 TMD.pdf#page=54|L28 TMD, p.54]] [^55]: Original PDF page 55: [[L28 TMD.pdf#page=55|L28 TMD, p.55]] [^56]: Original PDF page 56: [[L28 TMD.pdf#page=56|L28 TMD, p.56]] [^57]: Original PDF page 57: [[L28 TMD.pdf#page=57|L28 TMD, p.57]] [^58]: Original PDF page 58: [[L28 TMD.pdf#page=58|L28 TMD, p.58]]