In the practice of orthodontics, including the treatment of any signs or symptoms of TMD, one of the more common breaches of the duty that we owe our patients is not conducting an adequate comprehensive examination. Whenever we see a new patient, the first thing we need to do after we introduce ourselves is to ask the patient “What can I do for you?” “How can I help you?” “Why are you here?” What you are attempting to do is to elicit the patient’s chief complaint. This is the first step in conducting a comprehensive examination of the patient. You may find out that one of the patient’s chief complaints does or does not include symptoms that may relate to TMD. Attempting to elicit not only what the patient’s concerns are but also integrating this information with your impressions is important because it will guide you to have to make the first in a number of decisions, that being whether or not you want to treat this patient’s particular problem.

The standard of care requires that you MANAGE every patient appropriately. You are not obligated to treat every patient that enters your office nor are you required to treat every type of clinical problem. If you are comfortable treating patients presenting with TMD, fine; if you are not, the standard of care requires that you must either refuse to treat the patient or you can offer a referral to someone else who has more SKEE in this particular area. Referral is an appropriate way to manage a particular problem.

As the title of this chapter relates to TMD in the orthodontic patient, let us develop a hypothetical patient. She is in her early 30s, single, and employed in a middle management position. Her chief complaints are that she does not like the crowding of her upper and lower anterior teeth, nor the look of her smile, and she states that her jaw sometimes clicks on opening which she finds annoying at times. Assuming that you believe you possess the requisite SKEE in both orthodontics and TMD to treat the patient, what is next?

As with any examination, the critical risk management concerns are twofold. First, that the exam was appropriately conducted given the totality of the circumstances attached to any particular patient; and second, and of equal importance, is that the results of your examination were adequately documented. All findings, both positive and negative, need to be documented. This is a cardinal risk management principle. If a finding is negative, meaning it was not found to be present, then that negative finding is what needs to be documented. If the negative finding is not documented as such, it will not be presumed that the lack of documentation was because the finding was negative; rather it will be presumed that that part of the exam was not performed.

The first step after obtaining the patient’s chief complaint is to perform a comprehensive clinical examination and the first part of this activity involves obtaining adequate prior medical, dental, and social histories. This may or may not provide you with any information that impacts on your diagnosis and treatment of any given patient but one thing is certain, if you do not obtain this information, you will never know whether or not it was important. As there are numerous medical and psychological factors that can relate to treating an orthodontic patient who also happens to present with TMD symptomatology, not obtaining an adequate history is a breach of the standard of care owed to every patient.

The past dental history may also elicit relevant information such as whether or not the patient has undergone prior orthodontic treatment and if so what treatment was performed. In addition, you would want to know whether the TMD sign or symptom is acute or long standing as this may have some bearing on how you will manage a particular problem. Again, obtaining this information certainly falls within the standard of care.

A comprehensive clinical exam also includes a social history that encompasses looking into any habits or lifestyle activities that may relate to both the etiology of the malocclusion and the TMD symptomatology presented. In a TMD patient, a social history could also include the possibility of referring the patient for psychological assessment depending upon the circumstances of the patient’s presentation.

These three aspects, medical, dental, and social, of a patient’s history should not be ignored as they are core elements of formulating a differential diagnosis and an appropriate treatment plan for every patient. It relates to what we were taught at the beginning of our dental education – never treat a stranger.

The remainder of the clinical exam consists of a functional and extra oral examination, and an intraoral examination of the patient’s hard and soft tissues, and a radiologic examination. This is discussed in more detail in Chapter Three.

The functional examination is just that, an examination of the functional status of a soon to be orthodontic patient. Function includes an evaluation of the joints and an evaluation of the occlusion both static and dynamic.