History

You are confronted in your surgery one morning by a relatively new patient, Mrs Davies, who is a mother of two young children and is a teacher at a nearby private secondary school. On previous examinations, although she has always been polite and friendly, she has insisted on being seen on time and does not like to be kept waiting. She obviously has a very pressurised life that she balances between work and family commitments.

‘I have got ‘TMJ’. I have researched it on the internet and I know what needs to be done!’ This was her opening comment. She then delivered a rapid synopsis of her symptoms.

You insisted on taking a full and comprehensive history. For the last 3 weeks she has woken with pain on the left side of her face. This seems to be centred around her left ear, but extends up into her left temple and down the left mandible into her neck. She said that this side of her face feels ‘heavy’. When she wakes in the morning her jaw feels stiff to move. She complains that her front teeth, especially on the left side, feel generally sensitive. She notices this when she has cold milk on her cereal in the morning but she said that this gradually wears off as the morning progresses. The teeth were not tender to bite on. After the onset of her symptoms, she went to see her doctor because she thought that she had an ear infection. Her doctor examined her and, although there was no obvious evidence of an ear infection, prescribed some antibiotics. These produced no benefit. She described her discomfort as being a ‘dull ache’. She could not put one finger on the main source of her discomfort, indicating rather that it was diffuse. Her symptoms arose gradually and, as far as she was aware, there had been no particular initiating event.

You questioned her about her reduced range of movement and she said that the stiffness in her jaw was there for only a short period in the morning and generally wore off within an hour or so of waking. The limited movement was because of discomfort rather than because of a physical restriction of movement.

You asked her about joint sounds such as jaw joint clicking and she remembered that she had had an intermittent click from her left TMJ a couple of weeks ago but this had disappeared. She did recollect that it may have happened on one or two occasions since then but she could not be sure.

At this point, before you had even had time to start your clinical examination, she said ‘Will you X-ray it? I don’t want medication but I need a splint!’

On questioning her further she volunteered that she had researched this topic thoroughly on the internet and realised that provision of antidepressant medication was quite commonplace in the management of patients with ‘TMJ’. She had also read about cranial osteopathy which she thought might help but, most importantly, she knew that her bite could be the cause of the problem because she felt that she had started to grind her teeth.

She wanted you to adjust her bite to stop her doing this and thought that this could also be involved with the headaches that she had been having. She introduced this as a new symptom unrelated to anything that she had talked about previously. When you questioned this she said that she had recently started suffering from a chronic daily headache that was there when she woke in the morning and gradually wore off as the day progressed.

You are therefore left with a confused and confusing story.

Medical History

Mrs Davies has a history of peptic ulceration and is currently taking cimetidine.

Examination

She had an Angle’s class I, basal bone and incisal relationship.

Range of Movement

On examination, her range of movement was entirely within normal limits. She could open comfortably to 35 mm, and thereafter to a maximum of 40 mm. She could move her mandible laterally 8 mm to both the right and the left sides. The extreme ranges of movement were not painful but were ‘uncomfortable’. When you examined the pathway of her mouth opening, it was straight in the vertical plane. There were no transient or lasting deviations in her mouth movements.

Joint Sounds

You listened to her TMJs for joint sounds. There was no evidence of clicking from either the right or the left side on vertical or lateral movement. There was no evidence of any crepitation from either the right or the left side.

Signs of Bruxism

You examined her mouth intraorally for signs of active bruxism. She had marked ridging on the inside of her left cheek and generalised scalloping of the lateral border of her tongue on both sides. There was no obvious tooth attrition that could be attributed to parafunction. She did, however, have some occlusal facets that you thought were attributable to normal occlusal wear.

Temporomandibular Joint Tenderness

The left TMJ was tender on intra-auricular palpation of the posterior part of the condyle via the external auditory meatus. There was no lateral tenderness on palpation of the preauricular region and no tenderness of the left TMJ on gentle manipulation of the mandible to a retruded position.

Mandibular Muscle Tenderness

On examination of the mandibular muscles, the origin of the left masseter muscle was tender on bimanual palpation along the zygoma, as was the origin of the left temporalis muscle on digital examination in the anterior temporal fossa. There was no particular discomfort elicited on examination of the pterygoid muscles against resistance. There was, however, tenderness of the posterior belly of the digastric muscle on the left side, on palpation behind the ascending ramus of the mandible on the left.

Examination of the muscles on the right side was entirely normal. When you assessed the degree of tenderness of the muscles on the left side, the left temporalis muscle was more tender than the left masseter muscle.

Occlusion