Mr Jones, who is a 40-year-old businessman, attends for his routine check-up and examination. He is a regular 6-monthly attender and you have known him for several years and have always got on well with him, enjoying chatting about sport, which was a mutual interest.

When he attended on this occasion, however, he appeared distracted and not his normal relaxed self. He explained to you that he had had a throbbing headache off and on for the last couple of months. He had been to his doctor who had prescribed various analgesics but without any lasting benefit. He had read an article in one of the Sunday papers that headache could be associated with tooth grinding and tooth clenching, and he wanted you to examine him and give him your professional opinion as to whether you thought this was possible in his case.

He said that he woke up with a headache every morning and this gradually wore off during the day, only to return later. The painkillers his doctor prescribed were not really helping. He had been under considerable pressure at work because he was worried about redundancy as his company had not been performing very well recently. He said that he had not been sleeping well and on rare occasions he woke in the middle of the night with head pain.

He had been to the optician to have his eyes tested and was told that his prescription had not changed. He had been back to his doctor on several occasions but he felt that his doctor had ‘lost interest’. He did remember that he had had a heavy cold recently and he had again been back to his doctor who had prescribed antibiotics because he was concerned that he might have a sinus infection. He had finished two courses of antibiotics but again with no relief of his head pain. His doctor had also checked his ears and found no abnormalities. He had been referred to an ENT consultant who also told Mr Jones that there was nothing wrong with him and that he should have his teeth checked because he might be developing a tooth abscess.

It then became apparent that Mr Jones had two main concerns. The first, and the reason for him being less friendly than usual, was that, as he had been a patient of yours for many years and had been a regular attender, he thought that you might have missed something that had developed to a stage that was now causing him pain and ‘if so, you have some explaining to do!’.

He was embarrassed about mentioning his second concern which was that, as no diagnosis had as yet been reached, he was worried that there might be a ‘more sinister cause’ such as a brain tumour.

Examination

You first examined Mr Jones’s teeth and intraoral soft tissues and periodontal condition. His oral hygiene, as usual, was exemplary. He had no calculus and no accumulation of plaque. All soft tissues were healthy in appearance and colour. There was no pocketing and he had a BPE of 1 in all sextants.

While you were examining his dentition, he did volunteer that recently he had had sensitivity of his teeth, not in any specific area but more generalised. He said that this was especially bad when brushing his teeth in the morning and when having his cereal with cold milk, and was one of the factors that led him to believe that he might have a dental problem.

On clinical examination, it was apparent that Mr Jones’s mouth was caries free. He only had a few minimal restorations and there was no evidence of any problems with these. None of his teeth was tender to percussion but he felt that his canines and incisors were generally uncomfortable when you dried them with air from the syringe. There were no obvious wear facets on these teeth. All of his third molar teeth were erupted and in function. There was no evidence of pericoronitis.

Radiographs

You normally only took radiographs of Mr Jones’s teeth occasionally in accordance with the IR(ME)R 2000 guidelines. You checked your records and found that you had taken bite-wing radiographs 2 years previously but, in view of Mr Jones’s current concerns, you felt it justifiable to take right and left bite-wing radiographs on this occasion to allay his fears and satisfy yourself that no dental disease had developed.

Bite-wing radiographs were taken which showed there to be no caries and normal bone levels in all four quadrants.

Articulatory System Exam

You undertook your normal examination of the articulatory system and found him to have discomfort from both right and left TMJs on palpation via the external auditory meatus, when he experienced quite sharp discomfort. He also experienced mild discomfort on lateral palpation of the TMJs in the preauricular region on both sides of his face.

His range of vertical mandibular movement was slightly reduced. He could open to 33 mm, but could move his mandible to the right and the left 12 mm in both directions. His pathway of mouth opening was straight, indicating that both joints were acting synchronously.

Having palpated both right and left TMJs and listened to the joints with a stethoscope for joint sounds you could detect neither clicking nor crepitation.

You examined the jaw muscles and found mild tenderness of the origin of both right and left masseter muscles along the anterior part of the zygomatic arch, and quite marked tenderness in the anterior fibres of the temporalis muscle.

Even though there was no evidence of clicking at the time of the clinical examination, Mr Jones did say that, for the first time in his life, he had started to get occasional and intermittent jaw joint clicking first thing in the morning. He felt that this was coming mainly from his right TMJ. It did not happen every da/>