Jeffrey P. Okeson and Isabel Moreno Hay - fkg.usu.ac.idfkg.usu.ac.id/images/Bahan_Kuliah/Buku_McCullough/Clinical-Evaluation-of-Orofacial... · the information collected from the

Clinical Evaluation of Orofacial Pain

Jeffrey P. Okeson and Isabel Moreno Hay

AbstractPain felt in the head and neck can be verychallenging for the treating clinician. Thereare so many possible diagnoses, all of whichrequire specific treatments. Success can onlybe achieved by selecting the proper treatmentfor the pain condition. Therefore, differentialdiagnosis is the most critical element for beingsuccessful. Proper diagnosis can only beachieved by acquiring the needed informationfrom the patient. This chapter reviews theessential elements of taking a detailed painhistory and performing a thoroughexamination.

KeywordsOrofacial pain • Temporomandibular disor-ders • Pain history • TMD history • TMJ his-tory • Pain examination • Clinical evaluation •Cranial nerve • TMD evaluation • TMJevaluation

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

History of Orofacial Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2The Chief Complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Past Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Review of Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Psychological Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Cranial Nerve Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Eye Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Ear Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Cervical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Muscle Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Masticatory Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Extracapsular Versus Intracapsular Restrictions . . . . . . 18Evaluation of Oral Structures . . . . . . . . . . . . . . . . . . . . . . . . . 18

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Introduction

The ability of a clinician to establish a properdiagnosis lays the foundation for successful treat-ment. When the patient’s chief complaint is pain,the most important aspect is to understand theproblem and consequently establish a proper diag-nosis. It is critical to correctly identify the sourceof the problem in order to successfully eliminateor alleviate the pain. The diagnosis can only beestablished after a thorough clinical evaluation ofthe patient.

J.P. Okeson (*) • I. Moreno HayOrofacial Pain Program, College of Dentistry, Universityof Kentucky, Lexington, KY, USAe-mail: [email protected]; [email protected]

# Springer International Publishing AG 2016C.S. Farah et al. (eds.), Contemporary Oral Medicine,DOI 10.1007/978-3-319-28100-1_7-1

1

In the orofacial region, diagnosis can some-times be challenging as head and neck disordersfrequently lead to heterotopic pains that are felt inthe orofacial structures. In order to establish anaccurate diagnosis, this type of heterotopic pain,and its source, must be identified during the his-tory and clinical evaluation. To be effective, treat-ment must be directed towards the source of painand not towards the site.

An accurate diagnosis can be established withthe information collected from the history andclinical evaluation.

History of Orofacial Pain

The importance of taking a thorough historycannot be overemphasized in orofacial pain dis-orders. As much as 70–80% of the essentialinformation needed to make the diagnosis isarrived at from the history. This is unlike dentaldisease, where a relatively small percentage ofthe information needed for diagnosis is gatheredthrough the history, most coming from theexamination. In orofacial pain disorders, mostof the essential information for establishing theproper diagnosis will often come from thehistory.

The process of history taking is key in makingan accurate diagnosis. In this process, the clini-cian acquires the necessary information by ask-ing specific questions to the patient. This processcan be performed verbally and/or by means of awritten questionnaire. The former relies on theclinician’s ability to pursue a comprehensive setof extensive questions, whereas a written ques-tionnaire provides a thorough and consistentmethod of history taking. Nevertheless, the lattercannot detect nonverbal communication andsome patients have difficulty expressing theirproblem using a standard form. Thus, in mostinstances, the most complete method of historytaking is based on a predeveloped written ques-tionnaire, which is then reviewed by the clinicianallowing the patient to discuss and elaborate onany important areas.

The Chief Complaint

The starting point of history taking is to inquireabout the chief complaint, which is the reason forthe patient to seek medical care. The clinicianshould ask the patient to subjectively describethe primary symptom or concern, initially note itin the patient’s own words and then restate it intechnical language if indicated. The medical his-tory should always focus on the patient’s chiefcomplaint. However, in addition to the primarysymptom, the patient might present with othercomplaints. Some complaints can be secondaryto the chief complaint, while others may be inde-pendent. It is important to determine throughoutthe clinical evaluation the relationships betweenthe different complaints. Understanding theserelationships is crucial for pain management.Therefore, each of the patient’s complaints shouldbe enumerated and evaluated according to thefollowing factors

Pain LocationAn evaluation of the patient’s ability to locate thepain with accuracy provides relevant informationabout the patient’s condition. The clinician shouldbe aware that the patient’s description of the loca-tion of the complaint identifies only the site ofpain. The site of pain does not necessarily identifythe true source of pain. In some instances, thestructure from which the pain actually emanatesis in a different location than the site of pain. It isthe clinician’s responsibility to determine whetherit is also the true source of the pain.

A drawing of the head and neck can be veryhelpful. The patient will outline the location of thepain and can also draw arrows revealing any pat-terns of pain referral (Fig. 1). This allows thepatient to reflect in his own way all the pain sitesand can give the clinician a significant insightregarding the location and even the type of painthe patient is experiencing.

Furthermore, it is also helpful to have a draw-ing of the entire body so the clinician can take inconsideration the patient’s entire pain condition,particularly in chronic pain conditions, such as

2 J.P. Okeson and I. Moreno Hay

fibromyalgia (chronic widespread pain) or gener-alized arthritic conditions.

Pain OnsetThe circumstances associated with the onset of thecomplaint can give great insight about the etiol-ogy. For example, trauma such as a motor vehicleaccident can be the cause of a pain condition.Moreover, other related injuries, such as emo-tional trauma and even possible litigation, shouldalso be taken into consideration. In some cases,systemic illnesses or even jaw function can berelated to the onset of the pain condition. How-ever, sometimes the onset of the pain conditioncan be wholly spontaneous. It is important togather the information regarding the

circumstances associated with the onset of thepain complaint in a chronological order to beable to evaluate the possible cause-effectrelationship.

Pain CharacteristicsThe patient should specifically describe the qual-ity, behavior, intensity, and concomitant symp-toms of the pain complaint.

Pain QualityFurther evaluation of the pain complaint shouldinclude descriptors of the quality of pain experi-enced by the patient. The pain quality can beclassified as bright or dull, pricking, itching, sting-ing, burning, aching, pulsating, or throbbing. It

Right Front Left Back

Fig. 1 The patient is asked to draw the location and radiation patterns of the pain on these diagrams so the clinician cangain a better prospective of the entire pain condition

Clinical Evaluation of Orofacial Pain 3

should be taken into consideration that the samepain complaint might be described with more thanone designation.

Pain BehaviorThe pain behavior should be evaluated accordingto temporal behavior, duration, and localization:

I. Temporal Behavior: The frequency of paincan be classified as intermittent, when thepain complaint comes and goes leavingpain-free intervals of noticeable duration thatare not related to medication intake. If suchpain-free intervals do not occur, it is classifiedas continuous or persistent. When episodesof pain, whether continuous or intermittent,are separated by an extended period of free-dom from discomfort only to be followed byanother similar episode of pain, the syndromeis said to be recurrent.

II. Pain Duration: The duration of a pain episodeis an important descriptive feature that has asignificant diagnostic value. If pain durationcan be expressed in seconds, it is described asmomentary. Longer lasting pains are classi-fied into minutes, hours, or a day. Lastly,protracted pain continues from one day tothe next.

III. Localization: When the patient is able todescribe the exact location of the pain com-plaint, it is described as localized pain. Con-versely, if the location is less well defined andvague or variable anatomically, it is termed asdiffuse pain. If the localization of painbriskly changes, it is classified as radiating.A more gradually change in localization ofpain is described as spreading, and if it pro-gressively involves adjacent anatomic areas,the pain is called enlarging. The pain com-plaint is described as migrating if it changes

from one location to another. Referred pain isclinical expression of heterotopic pain.

Pain IntensityThe best method to measure indirectly the inten-sity of pain is by means of a visual analogue scale.The patient is asked to rate the pain by placing amark on a line that has “no pain” written on oneend and “the most severe pain possible”written onthe other end (Fig. 2). The mark can be measuredand a pain intensity rating can be calculated. Ascale of 0–5 or 0–10 can be used to measure theintensity of the pain, 0 being no pain and 5 or10 being the most pain possible. This is a usefulinstrument for quantification of pain. Although itis not appropriate tool to compare differentpatients since pain is a subjective experience andvaries greatly from patient to patient, this scalecan be helpful when comparing initial pain withpain at follow-up appointments to assess the treat-ment efficacy.

Concomitant SymptomsAny sensory, motor, or autonomic symptoms thataccompany the pain should be included in thehistory. Concomitant sensory symptoms such ashyperesthesia, hypoesthesia, anesthesia, paresthe-sia, or dysesthesia should be mentioned. Addi-tionally, changes in the special senses affectingvision, hearing, smell, or taste can also be present.Regarding motor changes, symptoms such asmuscular weakness, muscular contractions, oractual spasm should be recognized. Concomitantautonomic symptoms may include ocular symp-toms such as lacrimation, injection of the conjunc-tive, pupillary changes, and edema of the lids;nasal symptoms include nasal secretion and con-gestion; cutaneous symptoms have to do with skintemperature, color, sweating, and piloerectiongastric symptoms include nausea and indigestion.

Fig. 2 The patient is asked to place a mark on a line thathas “no pain”written on one end and “the most severe painpossible” written on the other end. The VAS score for pain

intensity is measured from the left. In this figure, the painintensity is quantified as 4/10


Any of these concomitant symptoms should bedocumented and the relationship to the pain com-plaint analyzed.

Flow of PainThe manner of flow is determined by whether theepisodes of pain are steady or paroxysmal. Asteady pain is a flowing type of pain that can bevariable in intensity or even intermittent. On theother hand, sudden volleys or jabs that may varyin intensity and duration characterize paroxysmalpain. When the volleys occur frequently, the painmay become nearly continuous.

Aggravating and Alleviating Factors

Effect of Functional ActivitiesThe effect of functional activities should beobserved and described. Activities such as shav-ing or washing the face may trigger the pain byminor superficial stimulation, touch or move-ment of the skin, lips, face, tongue, or throat.Furthermore, pain can also be induced as theresult of functioning of the joints and musclesthemselves in functional activities such astalking, chewing, yawning, turning the head,etc. In order to distinguish between the effectsof both functional activities, it can be very help-ful to stabilize of joints and muscles, and ulti-mately using topical anesthesia. The effect ofemotional stress, fatigue, and time of day shouldalso be recorded.

Similarly, parafunctional activities should alsobe investigated. Any intraoral or extraoral forceapplied to the jaw should be noted as a potentialcontributing factor to functional disturbance(Chun and Koskinen-Moffett 1990). The patientshould be questioned regarding parafunctionalhabits such as bruxism or any other oral habit.However, the clinician should be aware thatoften these activities occur at subconscious levelsand the patient may not accurately reporting them,particularly with bruxing and clenching. Otherparafunctional habits can include holding objectsbetween the teeth like a pipe, pencils, or occupa-tional implements. Moreover, extraoral forces canbe applied by holding a telephone between thechin and shoulder, resting the mandible in the

hands while sitting at a table or playing certainmusical instruments (Howard 1991).

Emotional StressEmotional stress can play a significant role in thepain complaint.When this is the case, patients willreport that the pain seems to be accentuated duringtimes of increased stress. It is important for boththe clinician and the patient to recognize thisrelationship, as the diagnosis and treatment planwill depend on it. The patient should bequestioned for any correlation between symptomsand high levels of emotional stress, and the peri-odicity of symptoms. The role that emotionalstress plays in the patient’s chief complaint canonly be identified with a thorough history. Thepresence of other psychophysiological disorders(e.g., irritable bowel syndrome (IBS), hyperten-sion, colitis) helps document the effect of stress onthe patient.

Sleep QualityThe quality of the patient’s sleep should also bereviewed because there is a relationship betweensome pain conditions and the quality of the sleep(Moldofsky et al. 1975; Moldofsky andScarisbrick 1976; Molony et al. 1986; Saletuet al. 2005). Patients should be asked about sleeplatency, awakenings throughout the night anddaytime tiredness. It is also important to assess ifthe pain condition actually awakes them fromsleep.

Disability and LitigationIt is relevant to the diagnosis and treatment plan torecognize if the patient is involved in any form oflitigation related to the pain complaint, as well asreceiving or applying for disability that will allowthe patient to receive compensation. In someinstances, secondary gain could be present andindirectly related to the chief complaint.

Past Consultations and TreatmentsAll the previous patient’s consultations and treat-ments should be thoroughly discussed andreviewed during the interview, so unnecessarytest or therapies are repeated. If the informationprovided the patient is incomplete or unclear, it is


recommended to contact the previous treating cli-nician to gather the appropriate information.

All past and present medications taken for thepain condition should be reviewed. The patientshould be asked to report dosages along with thefrequency taken, prescribing doctor and effective-ness in altering the chief complaint.

Additionally, the effect of different physicalmodalities on the pain condition, including appli-cation of hot and cold, massage, transcutaneouselectrical nerve therapy should be investigated.The response to such therapies may shed light onthe appropriate type and therapeutic intervention.

The patient should be asked to bring any occlu-sal appliance received to the evaluation appoint-ment. This evaluation may shed light on futuretreatment considerations.

Past Medical History

The history should include a complete past med-ical history to identify any major medical problemthat can play an important role in functional dis-turbances. Any past serious illnesses, hospitaliza-tions, operations, medications, or other significanttreatments should be noted. Even if the symptomsof the chief complaint are not related to a majormedical problem, the existence of such a medicalproblem may play an important role in selectingthe treatment plan. When indicated, treating phy-sicians should be contacted for additional infor-mation. It may also be appropriated to discussyour suggested treatment with the patient’s phy-sician when significant health problems arepresent.

Review of Systems

A complete history should also include appropri-ate questions concerning the presence of subjec-tive symptoms covering the organ systems:cardiovascular, hematologic, neurologic, diges-tive, respiratory, genitourinary, skin, musculo-skeletal, and endocrine. Any abnormalitiesshould be noted and any relationship with thepain complaint should be determined.

Psychological Evaluation

In acute pain conditions, a routine psychologicalevaluation may not be necessary, in chronic painconditions however, psychological factorsbecome more relevant and a psychological evalu-ation becomes essential. For this reason, chronicpain patients are best evaluated and managed by amultidisciplinary team.

To assess the patient’s psychological status,there are a wide variety of psychological measur-ing tools that can be used. Turk and Rudy (1987)developed the Multidimensional Pain Inventory(MPI) to evaluate the chronic pain experience,classifying the patient into three pain profiles:adaptive coping, interpersonal distress and dys-functional chronic pain. The dysfunctionalchronic pain profile of severe pain is accompaniedby functional disability, psychological impair-ment and low perceived life control.

The Symptom Check List 90 (SCL-90) isanother useful instrument (Derogatis 1977) thathelps evaluate the following eight psychologicalstates: somatization, obsessive-compulsivebehavior, interpersonal sensitivity, depression,anxiety, hostility, phobic anxiety, paranoid idea-tion, and psychoticism.

Psychologic assessment is also important notonly to identify mood and anxiety disorders, butalso other type of mental disorders such assomatic symptom and related disorders.According to the DSM-5 (Association TAP1994), these disorders are characterized by phys-ical complaints associated with significant levelsof distress and impairment that may not have anevident medical explanation. One of the mostcommon reported somatic symptoms is pain.These conditions include somatic symptom disor-der, functional neurological symptom disorder(also called conversion disorder), illness anxietydisorder (hypochondriasis), among others. Anevaluation of these conditions should be madeby a trained psychologist or psychiatrist.

Often the general practitioner may not haveimmediate access to psychological evaluationsupport. In this instance, the practitioner mayelect to use the IMPATH (Fricton et al. 1987) orthe TMJ Scale (Levitt et al. 1988). The new


DC/TMD (diagnostic criteria for temporomandib-ular disorders) (Schiffman et al. 2014) recom-mend the use of the following screening tools:the Patient Health Questionnnaire-4 (PHQ-4) todetect anxiety and depression, the GradedChronic Pain Scale (GCPS) to assess pain inten-sity and pain-related disability; the short form ofthe Jaw Functional Limitation Scale (JFLS) andthe Oral Behavioral Checklist (OBC) to evaluateparafunctional habits. These scales have beendeveloped for use in the private dental practiceto assist in evaluating clinical and certain psycho-logical factors associated with orofacial pains.These scales can assist the clinician in identifyingwhether psychological issues are an importantaspect of the patient’s pain condition. Althoughthese scales are helpful, they are not as completeas the above psychological tests and certainly donot replace personal evaluation by a clinicalpsychologist.

Clinical Evaluation

Once the history has been obtained, the clinicalevaluation is performed. The purpose of the clin-ical examination is to identify any variations fromnormal health and function of the orofacialstructures.

As part of the clinical evaluation of theorofacial pain, it is important to evaluate thegross function of the cranial nerves and the eyes,ears, and neck. If any abnormal findings are iden-tified, an immediate referral to the appropriatespecialty is indicated (Drum et al. 1993) .

Vital Signs

Blood pressure, pulse rate, respiration rate, andbody temperature should be taken as part of thegeneral examination.

Cranial Nerve Examination

In orofacial pain conditions, the gross function ofthe 12 cranial nerves should be tested to rule out

neurologic disorders. The cranial nerve examina-tion does not need to be complex. If any grossproblem relating to their function is identified, itshould be immediately and appropriatelyaddressed. The following evaluation procedurescan assess each cranial nerve.

Olfactory Nerve (I)The first cranial nerve has sensory fibers originat-ing in the mucous membrane of the nasal cavityand provides the sensation of smell. To test thefunction of the olfactory nerve, the patient is askedto distinguish between intense odors (i.e., vanilla,peppermint or chocolate). The mirror test can beused prior to assess nasal patency. The foggingpattern on the surface of the mirror reflects thenasal airflow.

Optic Nerve (II)The second cranial nerve is also sensory withfibers originating in the retina providing sight.Asking the patient to cover one eye and read afew sentences can assess the patient’s visual acu-ity. Each eye should be evaluated independently.Secondly, the visual field is evaluated by standingbehind the patient and slowly bringing the fingerstowards the nose while the patient is lookingforward. Patient should report when the clini-cian’s fingers are first noted. No discrepanciesshould exist between the right and left side.(Fig. 3)

Fig. 3 Visual field (optic nerve) test: with the patientlooking forward, the examiner’s fingers are brought aroundto the front from behind. The initial position at which thefingers are seen marks the extent of the visual field. Rightand left fields should be very similar


Oculomotor, Trochlear, and AbducentNerves (III, IV, VI)The third, fourth, and sixth cranial nerves supplymotor fibers to the extraocular muscles. To test thethree of them, the patient is asked to follow, withthe eyes and not the head, the finger as the clini-cian draws an “S” or “X.” The eyes should movesmoothly and similarly as they follow the clini-cian’s finger. Both pupils should be equal in size,round and reactive to light. To test the accommo-dation reflex, the patient is asked to change focusfrom a distant to a nearby object. In order to focusin when the object approaches the patient’s face,the pupils should constrict. The reactivity to lightis tested with direct light stimulus to the pupil. Thepupil not only constricts to direct light but alsoconstricts to light directed in the other eye (con-sensual light reflex) (Fig. 4).

Trigeminal Nerve (V)The fifth cranial nerve has two components: thesensory component responsible for the sensationfrom the face, scalp, nose, and mouth and themotor component that supplies the muscles ofmastication. Facial sensation can be tested bylightly stroking the face with a cotton tip bilater-ally over the three sensory regions innervated bythe ophthalmic, maxillary, and mandibularbranches of the trigeminal nerve: forehead,cheek, and lower jaw, respectively (Fig. 5). Thepatient should describe similar sensations on eachside. The trigeminal nerve also contains sensoryfibers from the cornea that can be tested simulta-neously with the corneal reflex. Light touch to thecornea innervated by the afferent fibers of thetrigeminal nerve with sterile cotton should elicita blink response innervated by efferent motorfibers of the VII nerve.

The gross motor input can be assessed by pal-pation of both masseter and temporal muscleswhen the patient clenches the teeth. The contrac-tion of the muscle should be felt equally on bothsides. (Fig. 6)

Facial Nerve (VII)The seventh cranial nerve is sensory and motor.The sensory component, supplying taste sensa-tions from the anterior portion of the tongue, is

evaluated by asking the patient to distinguishbetween sweet and salt using just the tip of thetongue. The patient is asked to raise both eye-brows, smile, and show the lower teeth to evaluatethe motor component, responsible for the musclesof facial expression. Any bilateral differences arerecorded during these movements.

Acoustic Nerve (VIII)The eighth cranial nerve supplies the senses ofbalance and hearing, also called vestibulo-cochlear nerve. Patients should be asked if they

Fig. 5 Trigeminal nerve sensory function test: cotton tipapplicators are used to compare light touch discriminationbetween the right and left maxillary branches of the tri-geminal nerve. The ophthalmic and mandibular branchesare also tested

Fig. 4 Pupil constriction test under direct light stimulus:the opposite pupil should also constrict, demonstrating theconsensual light reflex


have experienced any problems with balance orcoordination. To test balance and coordination,the patient is asked to walk heel-to-toe along astraight line. Hearing impairment can be evalu-ated by the clinician rubbing their first finger andthumb near the patient’s ear noting any differencebetween right and left sensitivities. (Fig. 7)

Glossopharyngeal and Vagus Nerves(IX, X)Both cranial nerves supply fibers to the back of thethroat. To test both nerves, symmetric elevation ofthe soft palate should be observed when thepatient pronounces vocal “a.” Similarly, by touch-ing the pharyngeal walls a gag reflex is induced.This gag reflex involves the afferent innervationof the glossopharyngeal nerve and the efferentmotor innervation of the glossopharyngeal andvagus nerve.

Accessory Nerve (XI)The spinal accessory nerve supplies fibers to thesternocleidomastoid and trapezius and muscles.To test the motor innervation of the sternoclei-domastoid muscle, the patient is asked to tilt thehead laterally against resistance. For the motorinnervation of the trapezius, the patient shrugs

the shoulders against resistance. Any differencesin muscle strength should be noted (Fig. 8).

Hypoglossal Nerve (XII)The twelfth cranial nerve innervates the musclesof the tongue. To test it, the patient is asked toprotrude the tongue and move it side-to-side aswell as pushing laterally against a tongue blade.Any deviations from the midline should be notedas well as differences in relative strength of bothsides.

Fig. 7 Gross hearing test: rubbing a strand of hair betweenthe finger and thumb near the patient’s ear to identify anydifference between right and left hearing sensitivities

Fig. 6 Trigeminal nerve motor function test: the patient isasked to clench the teeth together while the clinician feelsfor equal contraction of the right and left masseter muscles.This is also done for the temporalis muscles

Fig. 8 Spinal accessory motor function test: the patientmoves the head first to the right and then to the left againstresistance. The right and left sides should be relativelyequal in strength


Autonomic FunctionThe parasympathetic innervation of the oculo-motor or third cranial nerve is assessed simulta-neously while testing the pupillary light reflex.The facial or seventh and glossopharyngeal orninth nerves’ parasympathetic function can beevaluated by testing lacrimation and salivation.The presence of Horner’s syndrome character-ized by miosis, ptosis and facial anhidrosis,indicates and deficit in cranial sympatheticactivity.

If any abnormalities are noted during the cra-nial nerve evaluation, referral to a neurologistshould be made.

Eye Examination

In addition to the cranial nerve examination, anychanges in vision, diplopia, or blurriness of visionshould be documented as well as whether thisrelates to the pain problem. Pain felt in or aroundthe eyes should be noted and whether or notreading affects it. Reddening of the conjunctivaeshould be recorded along with any tearing orswelling of the eyelids.

Ear Examination

Ear pain is a common source of orofacial pain andneeds to be ruled out as the origin of the patient’schief complaint. Moreover, due to the proximityof the TMJ, it is not uncommon that patientsreport ear pain as an associated symptom. There-fore, an ear examination is recommended as partof the clinical examination of an orofacial paincondition. An otoscopic examination can beperformed by gentling pulling the auricle andinspecting the external auditory canal and tym-panic membrane. Tenderness upon pulling theauricle could be a clinical sign of otitis media. Ifany other abnormalities are noted such a swelling,infection, erythema, or hemorrhage, referral to anotorhinolaryngologist should be arranged for amore thorough evaluation. On the other hand,normal findings from an otologic examination

may be taken as encouragement to continue tosearch for the true source of pain (Fig. 9).

Cervical Evaluation

It is important to evaluate the presence of anycervical spine disorder that might be related tothe patient’s chief complaint. Pain arising fromthe cervical structures can refer pain to theorofacial structures. A simple screening examina-tion can be accomplished by examining the cervi-cal range of motion and the presence of painduring movement. With the patient seated in anupright position, neck flexion, extension, rotation,and lateral tilt are measured. There should be atleast 70! of rotation in each direction (Okeson2013a). The head should normally extend back-ward some 60! and flex downward 45!. Thisshould be possible to approximately 40! eachway. The presence of any pain during the tests orany limitation of movement should be noted(Fig. 10a–d).

If the clinician suspects that the patient has acervical spine disorder, referral for a more com-plete (cervicospinal) evaluation is indicated. Thisis important, since craniocervical disorders can beclosely associated with orofacial pain disorders

Fig. 9 Ear evaluation: an otoscope is used to visualize theexternal ear canal and the tympanic membrane for anyunusual findings. If abnormal findings are suspected thepatient should be referred to an otolaryngologist for athorough evaluation


(Clark 1987; Visscher et al. 2009; Fernandez-de-Las-Penas et al. 2009).

Muscle Evaluation

The muscle evaluation includes muscle palpationto determine the presence of pain or tendernessand muscular functional manipulation.

Muscle PalpationDigital palpation is a widely accepted method ofdetermining the presence of muscle tendernessand pain (Burch 1977; Okeson 2013a). Digitalpalpation produces a tissue deformation that incompromised muscle tissue can elicit pain (Frost1977). A healthy muscle tissue does not elicitpain; thus, when pain is reported upon palpation,it can be deduced that the muscle tissue has been

compromised by either trauma or fatigue. Anobjective quantitative assessment of pain or ten-derness upon pressure can be obtained by using apressure algometer (Fig. 11).

Palpation of the muscle is accomplishedmainly by applying soft but firm pressure withthe palmar surface of the middle finger and withthe index finger or forefinger testing the adjacentareas in a small circular motion.

Any pain or discomfort elicited during muscleexamination should be noted to later be used in theevaluation and assessment of progress.

Clinical Significance of Trigger PointsWhile performing a thorough muscle examina-tion, the clinician should identify the presence oflocalized, taut, hypersensitive bands of muscletissue (trigger points), and indicative ofmyofascial pain. When a trigger point is located,

Fig. 10 Cervical range of movement: (a) the patient isasked to look to the extreme right and the extreme left, (b)look upward fully, (c) look downward fully, and (d) bend

the neck to the right and left. Any restriction of movementis noted and considered in the pain diagnosis


the clinician should maintain the pressure over thetaut band to determine if a pattern of pain referralis elicited. Pressure should be applied for 4–5 sand the patient is asked if the pain is felt to radiatein any direction. The patterns of referred (hetero-topic) pain should be documented on a drawing ofthe face for future reference in identifying anddiagnosing the pain conditions.

Travell and Simons outlined the specific pat-tern of referred pain from various trigger pointlocations (Travell and Simons 1983; Simonset al. 1999), but further studies are still needed toestablish reliable diagnostic criteria for myofascialtrigger points. An understanding of these commonreferral sites may help the clinician who isattempting to diagnose a facial pain problem. Forexample, when a patient’s chief complaint is head-ache, careful palpation of the aforementionedneck muscles for trigger points will demonstrateits source (Travell and Rinzler 1952).

When the source of pain is difficult to identify,a diagnostic anesthetic injection delivered to thetrigger point can be very helpful to confirm thediagnosis. Local anesthetic blocking often notonly provides diagnostic information, but it canalso have therapeutic value (Okeson 2013b).

Once the trigger point has been located, thetissue should be cleaned with alcohol, and thetaut band trapped between two fingers. When theneedle is inserted in the area, aspiration with thesyringe should be performed to avoid injection of

local anesthetic into a vessel. Once the injectionhas been completed, it is recommended to applyslight pressure at the site with a sterile gauze for10 to 15 s. The clinician must be familiar with thelocal anatomy to avoid other structures in thevicinity. A few minutes after the infiltration,patient should be asked to report pain relief notonly at the site of the injection but also the referredlocation. In some cases, the benefit of the injectioncan last longer than the effect of the localanesthetic.

A routine muscle examination should includethe palpation of the following muscles:temporalis, masseter, sternocleidomastoid, andposterior cervical (e.g., the splenius capitis andtrapezius). Simultaneous bilateral pressure isrecommended except for the sternocleidomastoid.To perform a proper muscle evaluation, it is cru-cial to have a thorough understanding of the anat-omy and function of the muscles.

Temporalis MuscleThe temporalis muscle is a fan-shaped muscle thatcan be divided into three functional areas, andeach area is independently palpated. The musclefibers of the anterior region run in a verticaldirection and can be palpated above the zygomaticarch and anterior to the TMJ. The fibers in themiddle region run in an oblique direction acrossthe parietal area and are palpated directly abovethe TMJ and superior to the zygomatic arch. Thefibers in the posterior region run horizontally andcan be palpated above and behind the ear(Fig. 12a–c).

To determine the proper position of the fingers,the patient is asked to clench the teeth together.The temporalis will contract and the fibers shouldbe felt beneath the fingertips. It is helpful to bepositioned behind the patient and to palpate themuscle areas bilaterally and simultaneously.

It is important also to palpate the tendon of thetemporalis muscle. The fibers of the temporalismuscle converge into a tendon that runs mediallyto the zygomatic arch and inserts onto thecoronoid process of the mandible. Temporalistendonitis can generate pain in the body of themuscle as well as referred pain behind the adja-cent eye (retro-orbital pain). The tendon of the

Fig. 11 Pressure algometer can be used to obtain anobjective quantitative assessment of pain or tendernessupon palpation


temporalis is palpated by placing the fingerintraorally on the anterior border of the ramusand moved up until the coronoid process and theinsertion of tendon are palpated. The patient isasked to report any discomfort or pain.

Masseter MuscleThe masseter muscle is palpated bilaterally at itssuperior and inferior attachments. The fingersshould be placed slightly inferior to the zygomaticarch, just anterior to the TMJ. Then the fingers dropalong the muscle fibers to the inferior attachment onthe inferior border of the ramus (Fig. 13a, b).

Sternocleidomastoid MuscleThe palpation of the sternocleidomastoid (SCM)is done bilaterally near its insertion on the outersurface of the mastoid fossa, behind the ear. Theentire length of the muscle is palpated, down to itsorigin near the clavicle. The patient is asked toreport any discomfort during the procedure. The

sternocleidomastoid muscle is a frequent sourceof referred pain to the temporal, joint, and ear area(Fig. 14a, b).

Posterior Cervical MusclesThe posterior cervical muscles are the majorgroup responsible for cervical function. Thisgroup of muscles includes trapezius, longissimus(capitis and cervicis), splenius (capitis andcervicis), and levator scapulae. They originate atthe posterior occipital area and extend inferiorlyalong the cervical spine region.

To palpate this group of muscles, the examinerplaces the fingers behind the patient’s head at theorigin of the muscles. The fingers move down thelength of the neck muscles through the cervicalarea. It is important to be aware of referral painfrom these muscles since they are a commonsource of frontal headache. The patient isquestioned regarding any discomfort during pal-pation (Fig. 15a, b).

Fig. 12 Palpation of the temporal muscles: (a) the anterior region, (b) the middle region, and (c) the posterior region


The splenius capitis is palpated at its attach-ment to the skull at a small depression just poste-rior to the attachment of the SCM. Any pain,tenderness, or trigger points noted during palpa-tion are recorded.

The trapezius is an extremely large muscle ofthe back, shoulder, and neck that can be easilypalpated and is a common source of referred painand headache. The upper part is palpated frombehind the SCM, inferolaterally to the shoulder,and any trigger points are recorded (Fig. 16).

Functional ManipulationAs previously mentioned, the muscle examinationalso includes the muscular functional manipula-tion. During functional manipulation, each mus-cle is contracted and then stretched. If the muscle

is a true source of pain, both activities willincrease the pain. This technique is used for mus-cles that are impossible or nearly impossible topalpate manually. There are three muscles that arebasic to jaw movement but impossible or nearlyimpossible to palpate: the inferior lateral ptery-goid, superior lateral pterygoid, and medial pter-ygoid muscles. All three muscles receive theirinnervation from the mandibular branch of thetrigeminal (V) nerve.

The lateral pterygoid originates on the lateralwing of the sphenoid bone and the maxillarytuberosity and inserts on the neck of the mandib-ular condyle and the TMJ capsule. The medialpterygoid has a similar origin, but it extendsdownward and laterally, to insert on the medialsurface of the angle of the mandible. Although the

Fig. 14 Palpation of the sternocleidomastoid muscles: (a) superior near the mastoid process and (b) inferior near theclavicle

Fig. 13 Palpation of the masseter muscles: (a) the superior attachment to the zygomatic arch and (b) the superficialmasseter muscle near the lower border of the mandible


medial pterygoid can be directly palpated by plac-ing the finger in the lateral aspect of the pharyn-geal wall of the throat, this palpation is difficultand sometimes uncomfortable for the patient (gagreflex).

If pain is increased during resisted protrusionof the mandible, the inferior lateral pterygoidshould be suspected as a source of pain. If painincreases during power stroke (clenching) in max-imum intercuspation, the inferior or the superiorlateral pterygoid might be the source of pain.Finally, to test the medial pterygoid as the sourceof pain, it will increase when the mouth is opened,when clenching the teeth and clenching on a sep-arator. A more detailed description can be foundin other texts (Okeson 2013b).

Masticatory Evaluation

The masticatory structures can be a commonsource of orofacial pain. To identify any pain ordysfunction, a thorough examination should beperformed. The clinician should evaluate therange of movement, the TMJs, as well as theoral structures.

Mandibular Range of MotionThe range of movement during mouth opening isthe distance that the jaw travels between maxi-mum intercuspation and mouth opening. Therange of motion is calculated by measuring thedistance in millimeters (mm) between the incisaledges of the maxillary and mandibular anteriorincisors, adding the amount of positive frontaloverlap in patients with overbite, or subtractingthe negative frontal overlap in cases of anterioropen bite. An initial measurement of maximumcomfortable opening is obtained by asking thepatient to open slowly until the pain is firstnoted. The maximum mouth opening is thenrecorded by asking the patient to open as wide aspossible despite the pain. In the absence of pain,no restrictions are expected; thus, the maximumcomfortable opening and the maximum mouthopening are identical (Fig. 17a, b).

The normal range of mouth opening is 53 to58 mm (Agerberg and Osterberg 1974) measuredbetween the incisal edges of the maxillary andmandibular teeth. A patient can normally open a

Fig. 15 (a) palpation of muscular attachments in the occipital region of the cervical spine. (b) the fingers are broughtinferiorly down the cervical area and the muscles are palpated for pain and tenderness

Fig. 16 The trapezius is palpated as it ascends into theshoulder structures


maximum 40 mm or more, even at the age of6-year-old (Solberg 1976; Vanderas 1992).Among young adults only 1.2% open less than40 mm and among healthy elderly population15% (Bitlar 1991); therefore, less than 40 mm isconsider as a reasonable point to determinerestriction upon mouth opening. Nevertheless,the patient’s age and body size should always betaken into consideration.

When restriction in mouth opening is noted, itis helpful to test the “end feel.” The end feeldescribes the characteristics of the restrictionthat limits the full range of joint movement(McCarroll et al. 1987). The end feel can beevaluated by placing the fingers between thepatient’s upper and lower teeth and applying gen-tle but steady force in an attempt to passivelyincrease the interincisal distance. If the end feelis “soft,” increased opening can be achieved but itmust be done slowly. A soft end feel suggestsmuscle-induced restriction (Hesse et al. 1990). Ifno increase in opening can be achieved, the endfeel is said to be “hard.” Hard end feels are morelikely associated with intracapsular sources (e.g.,a disc dislocation) (Fig. 18).

The range of movement of excursive move-ments of the mandible is also evaluated. Thepatient is instructed to move his mandible later-ally and to protrude. Any excursive movementsless than 8 mm are considered a restrictedmovement.

Not only is the distance during mandibularmovements evaluated but also the path taken bythe midline of the mandible. In the healthy masti-catory system, a straight opening and protrudingpathway should be observed. During mouth open-ing, two types of abnormalities can occur: devia-tions and deflections. A deviation is considered asany shift of the jaw midline during opening thatdisappears with continued opening (a return tomidline). It is a result of the incoordination ofthe movement of both condyles, usually due to adisc derangement in one or both joints. Thestraight midline path is resumed once the condylehas overcome this interference. A deflection is

Fig. 17 Mouth opening evaluation: (a) The patient isasked to open the mouth until pain is first felt. At thispoint the distance between the incisal edges of the anteriorteeth is measured. This measurement is called the

maximum comfortable mouth opening. (b) The patient isthan asked to open as wide as possible even in the presenceof pain. This measurement is called the maximum mouthopening

Fig. 18 Checking the “end feel”. Gentle but steady pressureis placed on the lower incisors for approximately 10–15 s.Increased mandibular opening indicates a soft end feel (usu-ally associated with a masticatory muscle disorder)


any shift of the midline to one side that becomesgreater with opening and does not disappear atmaximum opening (does not return to midline).It is due to restricted movement in one joint. Thesource of the restriction varies and must beinvestigated.

Temporomandibular Joint ExaminationAny signs or symptoms associated with pain anddysfunction of the temporomandibular joints areevaluated.

Temporomandibular Joint PainAny pain or tenderness arising from the TMJs isexamined by digital palpation of the joints duringpostural position and dynamic movements of themandible. To locate the lateral aspect of the TMJ,the patient is asked to open and close a few times;in this way the clinician can feel the lateral poles ofthe condyles passing downward and forwardacross the articular eminences. Once the fingertipsare placed over the lateral aspect, both TMJs arepalpated simultaneously by applying pressure tothe joint area. Once the symptoms are recorded in aclosed mouth position, the patient is asked to openmaximally, and the posterior aspect of the TMJ isthen palpated by rotating the fingertips slightlyposterior. Posterior capsulitis and retrodiscitis areclinically evaluated in this manner. The symptomsassociated with the opening and closing mouthmovement should be recorded (Fig. 19a, b).

The clinician must have a sound understandingof the anatomy of the region, to evaluate thetemporomandibular joint effectively. When thepatient is asked to clench and the clinician’s fin-gers are placed properly over the lateral poles ofthe condyles very little to no movement is felt.However, if the fingers are misplaced only 1 cmanterior to the lateral pole and the deep portion ofthe masseter can be felt contracting. In this ana-tomic region, a portion of the parotid glandextends to the region of the joint, the clinicianshould be aware that parotid gland related symp-toms can also arise from this area. A correct dif-ferential diagnosis should be established toidentify whether the symptoms are originatingfrom the joint, muscle, or gland. The basis oftreatment will be determined by this evaluation.

Temporomandibular Joint DysfunctionTemporomandibular joint dysfunction can be sep-arated into two types: joint sounds and jointrestrictions.

Joint SoundsJoint sounds can be generally classified as eitherclicks or crepitation. A click is defined as a singlesound of short duration. If it is relatively loud, itcan be referred to as a pop. On the other hand,crepitation or crepitus is a multiple crackling,grating, or rattling sound. Crepitation is mostcommonly associated with osteoarthritic changes

Fig. 19 Palpation of the TMJ: (a) the lateral aspect of thejoint is palpated with the mouth closed. (b) The patient isthen asked to open and close the mouth noting any pain or

joint sounds. When the mouth is fully opened, the fingercan be moved behind the condyle to palpate the posterioraspect of the joint


of the articular surfaces of the joint (Bezuur et al.1988).

Joint sounds can be assessed by placing thefingertips over the lateral surfaces of the jointduring mouth opening and closing movementsor by using a stethoscope or a joint sound record-ing device. When these more sensitive devices areused the clinician must appreciate that many moresounds will be detected than mere palpation,which might not have any clinical significance.In fact, it might lead the clinician to unnecessarytreatment. Therefore, in most instances, palpationtechniques are more than adequate to assess TMJsounds.

It is not recommended to examine the TMJsounds by placing the fingers inside the patient’sears. This technique can actually produce jointsounds that are not present during normal functionof the joint (Hardison and Okeson 1990) by forc-ing the ear canal cartilage against the posterioraspect of the joint producing additional sounds.

The range of mandibular movement associatedwith the sound should also be recorded. Theinterincisal distance associated with the soundwill be noted during opening and closingmovements.

The presence or absence of joint sounds isassociated with the disc position and providesinformation regarding the TMJ dynamics. How-ever, the absence of sounds does not alwaysmean normal disc position. In one study 15%of silent, asymptomatic joints were found tohave disc displacements on arthrograms(Westesson et al. 1989; Westesson et al. 1990).Thus, all the clinical findings should be taken inconsideration to evaluate the clinical signifi-cance of joint sounds.

Joint RestrictionsAny irregularities or restrictions during mandibu-lar movements should be noted. Restricted move-ments of the mandible are caused by eitherextracapsular or intracapsular sources. The formerare generally the muscles and therefore relate to amuscle disorder. The latter are generally associ-ated with the TMJ disc-condyle function and thesurrounding ligaments and thus are usually relatedto a disc derangement disorder. Extracapsular and

intracapsular restrictions present with differentcharacteristics.

Extracapsular Versus IntracapsularRestrictions

In order to establish a differential diagnosisbetween extracapsular and intracapsular restric-tions, the following characteristics should betaken into consideration.

The main characteristic of extracapsularrestrictions is that normal eccentric movementsare present whereas opening movement isrestricted. Usually, the sources of the extra-capsular restrictions are typically elevator musclespasms and pain. These muscles tend to restricttranslation and thus limit opening. The restrictioncan range anywhere from 0 to 40 mminterincisally. With this type of restriction, thepatient is usually able to increase opening slowly,but the pain is intensified (soft end feel).

A deflection of the incisal path during open-ing can be observed with extracapsular restric-tions. The direction of the deflection depends onthe location of the muscle that causes the restric-tion. If the restricting muscle is lateral tothe joint (as with the masseter), the deflectionduring opening will be to the ipsilateral side.If the muscle is medial (as with the medialpterygoid), the deflection will be to thecontralateral side.

On the other hand, intracapsular restrictionscan be easily differentiated from the extra-capsular restrictions. An intracapsular restrictionlimits the translation of the TMJ but does notinterfere with the rotation of the condyle. As aresult, the patient is able to open between 25 to30 mm, which also depends if one or both TMJsare involved. A deflection of the incisal pathduring opening to the ipsilateral (affected) sidewill be observed.

Evaluation of Oral Structures

The oral structures including teeth and supportivestructures must be carefully examined.


Mucogingival TissuesThe gingiva and entire oral mucosa should betested by touch, pinprick, and manual palpationto identify areas of abnormal sensibility. Visualinspection of the superficial mucogingival tissuesof the mouth and throat is done to identify hyper-emia, inflammation, abrasion, ulceration, neo-plasm, or other abnormality.

Dental TissuesThere is no doubt that pains in the mouth and facestem most frequently from local dental causes,and a thorough examination of the teeth is anindispensable part of the orofacial examination.Odontogenic pains have the propensity to simu-late many other pain disorders, and hence, carefulexamination is needed to arrive at a diagnosis.

PeriodontumThe periodontal condition, especially in the regionof the pain, should be carefully evaluated. Gingi-val tissue color and surface texture should benoted. A periodontal probe should be used toidentify any loss of gingival attachment orpocketing that might be associated with the pain.The tooth should be percussed apically and later-ally to determine any relationship to the pain.Radiographs should be taken to help identify anychanges in the alveolar bone support of the teeth(e.g., widening of the periodontal space,osteosclerosis, hypercementosis).

Whenever tooth mobility is present, it canresult from either loss of bony support, such asperiodontal disease, or by unusual traumaticocclusal forces. Both factors should be takeninto consideration.

OcclusionTo examine a patient’s occlusal condition, it isnecessary to have an appreciation of what is con-sidered normal and what is considered function-ally optimal, as these two conditions are notidentical. The clinician must be aware that theocclusal condition is rarely a factor in the distur-bance and by merely examining an occlusal con-dition, cannot determine the relationship with theorofacial pain disorder. Although some studieshave suggested a relationship between different

malocclusions and the symptoms of TMD(Kirveskari et al. 1992; Tanne et al. 1993;Egermark-Eriksson et al. 1987), others do notseem to corroborate this statement (Gremillion2006; DeBoever and Adriaens 1983; McNamaraet al. 1995; Wadhwa et al. 1993; Manfredini et al.2014). To this date, the controversy still remainsand the relationship of dental occlusion andorofacial pain conditions is likely to be associatedwith the orthopedic instability of the masticatorysystem.

The assessment of the orthopedic instability ofthe masticatory systems begins with an occlusalevaluation when the condyles are in the mostmusculoskeletal stable position. This position isachieved when the TMJ condyles are located inthe most superior and anterior position in themandibular fossae, against the posterior slopesof the articular eminences, with the discs properlyinterposed (also termed, centric relation). In thisposition, the mandible can then be purely rotatedopened and closed approximately 20 mminterincisally, while the condyles remain in theirmusculoskeletal stable position.

In order to guide the patient to a musculoskel-etal stable position the patient should beapproached in a soft, gentle, reassuring, andunderstanding manner. The patient should be asrelaxed as possible lying on the back with thechin pointed upward. Lifting the chin upwardplaces the head in an easier position to locatethe condyles near the superior and anterior posi-tion (Fig. 20a). The clinician sitting behind thepatient should place the four fingers of each handon the lower border of the mandible with thesmallest finger behind the angle of the mandible.It is important to locate the fingers over the boneand not in the soft tissues of the neck. Next, boththumbs are placed over the symphysis of the chinso they touch each other between the chin andthe lower lip. When the hands are in this posi-tion, the mandible is gently guided by upwardforce placed on its lower border and angle withthe fingers, while at the same time the thumbspress downward and backward on the chin. Theoverall force on the mandible is directed so thecondyles will be seated in their most superior andanterior position braced against the posterior


slopes of the eminences. Firm but gentle force isneeded to guide the mandible so as not to elicitany protective reflexes (Dawson 1989;Fig. 20b–e).

The movement begins with the anterior teethno more than 10 mm apart to ensure that the

temporomandibular ligaments have not forcedtranslation of the condyles. The mandible is posi-tioned with a gentle arcing until it freely rotatesaround the musculoskeletal stable (CR) position.This arcing consists of short movements of 2 to4 mm. The occlusal contacts are then verified by

Fig. 20 Amanual procedure to locate the most musculos-keletally stable position of the TMJs. (a) The patient isreclined and the chin is directed upward. (b and c) The fourfingers of each hand are placed along the inferior border ofthe mandible with the small fingers behind the mandibularangle. (d and e) The thumbs meet over the symphysis of the

chin. Mild and controlled force is directed downward onthe chin while applying superior and anterior force at theangle of the mandible. These combined forces direct thecondyles into the most superior-anterior position in thefossae


means of an articulating paper or alternativelywith Shim stock (0.0005-inch-thick Mylar strip).

If orthopedic stability is present, the teethshould occlude in the maximum intercuspationwith no slide or less than 2 mm. Only discrepan-cies of more than 2 mm between the orthopedicmusculoskeletal stable position and the maximumintercuspation are defined as orthopedic instabil-ity. The clinician should be aware that the pres-ence of a significant shift does not in itselfrepresent an etiology of orofacial pain. Mostpatients with significant shifts have no painsymptoms.

In some instances, patients might complainfrom a sudden change in the intercuspal positiondirectly related to a functional disturbance. Thepatient is fully aware of this change and can beinduced by muscle disorders and intracapsulardisorders. This is known as an “acute malocclu-sion” (Okeson 2013a). When this occurs, the cli-nician needs to appreciate that this malocclusionis not causing the disorder but is a result of thedisorder.

Muscle spasms and protective co-contractionare muscle disorders that can alter the posturalposition of the mandible. When this occurs andthe teeth are brought into contact, an altered occlu-sal condition is felt by the patient. For example,spasms of the inferior lateral pterygoid cause thecondyle on the affected side to be pulled anteriorand medially, resulting in open bite between theposterior teeth on the ipsilateral side and heavyanterior tooth contacts on the contralateral side.

Regarding the intracapsular disorders, a rapidchange in the relationship of the articular surfacesof the joint can create an acute malocclusion, forexample, in retrodiscitis which is a condition thatseparates the bony structures inside the TMJ dueto inflammation or trauma. In this instance, theipsilateral posterior teeth may not contact and thecontralateral posterior teeth may contact heavier.

Moreover, no pain or discomfort should beelicited during the occlusal evaluation. If pain isproduced, it is likely due to an intracapsular dis-order exists, as a result of loading the retrodiscaltissues. Since these symptoms aid in establishinga proper diagnosis, they are important and aretherefore recorded.

It should be noted that when an acute maloc-clusion is present, the clinician needs to deter-mine what has caused the acute change in thebite and not attempt to blame this on producingthe disorder. In most instances, when the causeof the acute malocclusion is identified and elim-inated, the occlusion will return to its normalrelationship.

Conclusions

The ultimate goal of every clinician is to helpeliminate, or at least alleviate, the patient’s chiefcomplaint that brings him or her to seek care. Thiscan only be accomplished by understanding theprecise problem causing the patient to suffer.Establishing the correct diagnosis is essential forselecting the most appropriate treatment strategy.However, in the head and neck, pain can be a verycomplicated problem. Therefore, it is essentialthat all the information needed to establish thecorrect diagnosis is acquired and evaluated. Thischapter has highlighted the manner by which thisinformation can be gained through a proper his-tory and examination procedure. These skills arebasic and essential to successful painmanagement.

Cross-References

▶Arthritic Diseases Affecting the TMJ▶Biopsychosocial Considerations for OrofacialPain

▶Burning Mouth Syndrome▶Classification of Orofacial Pain▶Headache▶ Internal Derangements of the Temporomandib-ular Joint

▶Masticatory Muscle Pain▶Neuropathic Orofacial Pain▶Neurovascular Orofacial Pain▶Oral Appliance Therapy for Sleep DisorderedBreathing

▶Orofacial Pain and Sleep▶Orofacial Pain Associated with Oral MucosalDisease and Cancer


▶Orofacial Pain in the Medically ComplexPatient

▶ Sleep Bruxism▶ Sleep Medicine for Oral Medicine Specialists

References

Agerberg G, Osterberg T. Maximal mandibular move-ments and symptoms of mandibular dysfunction in70-year old men and women. Sven Tandlak Tidskr.1974;67(3):147–63.

Association TAP. Diagnostic and statistical manual ofmental disorders (DSM-IV). 4th ed. Washington, DC:American Psychiatric Association; 1994.

Bezuur JN, Habets LL, Hansson TL. The recognition ofcraniomandibular disorders – a comparison betweenclinical, tomographical, and dental panoramic radio-graphical findings in thirty-one subjects. J OralRehabil. 1988;15(6):549–54.

Bitlar G. Range of jaw opening in a elderly non-patientpopulation. J Dental Res. 1991;70(special issue):abstr#1225, 419.

Burch JG. Occlusion related to craniofacial pain. In: AllingCC, Mahan PE, editors. Facial pain. 2nded. Philadelphia: Lea & Febiger; 1977. p. 165–80.

Chun DS, Koskinen-Moffett L. Distress, jaw habits, andconnective tissue laxity as predisposing factors to TMJsounds in adolescents. J Craniomandib Disord FacialOral Pain. 1990;4:165.

Clark GT. Diagnosis and treatment of painful temporoman-dibular disorders. Dent Clin N Am. 1987;31(4):645–74.

Dawson PE. Evaluation, diagnosis and treatment of occlu-sal problems. 2nd ed. St Louis: The CV Mosby Co;1989. p. 28–34.

DeBoever JA, Adriaens PA. Occlusal relationship inpatients with pain-dysfunction symptoms in the tempo-romandibular joint. J Oral Rehabil. 1983;10:1–7.

Derogatis LR. SCL-90-R: administration, scoring and pro-cedures manual-II for the revised version. Towson:Clinical Psychometric Research; 1977.

Drum RK, Fornadley JA, Schnapf DJ. Malignant lesionspresenting as symptoms of craniomandibular dysfunc-tion. J Orofac Pain. 1993;7:294–9.

Egermark-Eriksson I, Carlsson GE, Magnusson T. A long-term epidemiologic study of the relationship betweenocclusal factors andmandibular dysfunction in childrenand adolescents. J Dent Res. 1987;66(1):67–71.

Fernandez-de-Las-Penas C, Galan-Del-Rio F, Ortega-Santiago R, Jimenez-Garcia R, Arendt-Nielsen L,Svensson P. Bilateral thermal hyperalgesia in trigemi-nal and extra-trigeminal regions in patients withmyofascial temporomandibular disorders. Exp BrainRes. 2009;202:171–9.

Fricton J, Nelson A, Monsein M. IMPATH:microcomputerassessment of behavioral and psychosocial factors in

craniomandibular disorders. J Craniofac Genet DevBiol. 1987;5:372–81.

Frost HM. Musculoskeletal pains. In: Alling CC, MahanPE, editors. Facial pain. 2nd ed. Philadelphia: Lea &Febiger; 1977. p. 140.

Gremillion HA. The relationship between occlusion andTMD: an evidence-based discussion. J Evid BasedDent Pract. 2006;6(1):43–7.

Hardison JD, Okeson JP. Comparison of three clinicaltechniques for evaluating joint sounds. Cranio. 1990;8(4):307–11.

Hesse JR, Naeije M, Hansson TL. Craniomandibular stiff-ness toward maximum mouth opening in healthy sub-jects: a clinical and experimental investigation. JCraniomandib Disord. 1990;4(4):257–66.

Howard JA. Temporomandibular joint disorders, facialpain and dental problems of performing artists. In:Sataloff R, Brandfonbrener A, Lederman R, editors.Textbook of performing arts medicine. New York:Raven Press; 1991. p. 111–69.

Kirveskari P, Alanen P, Jamsa T. Association betweencraniomandibular disorders and occlusal interferencesin children. J Prosthet Dent. 1992;67(5):692–6.

Levitt SR, McKinney MW, Lundeen TF. The TMJ scale:cross-validation and reliability studies. Cranio. 1988;6(1):17–25.

Manfredini D, Perinetti G, Guarda-Nardini L. Dentalmalocclusion is not related to temporomandibularjoint clicking: a logistic regression analysis in apatient population. Angle Orthod. 2014;84(2):310–5.

McCarroll RS, et al. Mandibular border positions and theirrelationship with peripheral joint mobility. J OralRehabil. 1987;14:125.

McNamara Jr JA, Seligman DA, Okeson JP. Occlusion,Orthodontic treatment, and temporomandibular disor-ders: a review. J Orofac Pain. 1995;9(1):73–90.

Moldofsky H, Scarisbrick P. Induction of neurasthenicmusculoskeletal pain syndrome by selective sleep dep-rivation. Psychomatic Med. 1976;38:35–44.

Moldofsky H, Scarisbrick P, England R, SmytheH. Musculosketal symptoms and non-REM sleepdisturbance in patients with fibrositis syndrome andhealthy subjects. Psychosom Med. 1975;37(4):341–51.

Molony RR, MacPeek DM, Schiffman PL, et al. Sleep,sleep apnea, and the fibromyalgia syndrome.J Rheumatol. 1986;13:797–800.

Okeson JP. Chapter 9: History and examination for TMD.Management of temporomandibular disorders andocclusion. 7th ed. St. Louis: Elsevier; 2013a.p. 170–221.

Okeson JP. Management of temporomandibular disordersand occlusion. 7th ed. St. Louis: Elsevier; 2013b.

Saletu A, Parapatics S, Saletu B, Anderer P, Prause W,Putz H, et al. On the pharmacotherapy of sleep brux-ism: placebo-controlled polysomnographic and psy-chometric studies with clonazepam.Neuropsychobiology. 2005;51(4):214–25.


Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G,Goulet JP, et al. Diagnostic criteria for temporomandib-ular disorders (DC/TMD) for clinical and researchapplications: recommendations of the InternationalRDC/TMD Consortium Network* and Orofacial PainSpecial Interest Groupdagger. J Oral Facial Pain Head-ache. 2014;28(1):6–27.

Simons DG, Travell JG, Simons LS. Travell & Simons’myofascial pain and dysfunction: a trigger point man-ual. 2nd ed. Baltimore: Williams & Wilkins; 1999.

SolbergW. Occlusion-related pathosis and its clinical eval-uation. Clinical dentistry. 2nd ed. New York: Harper &Row Publishers; 1976. p. 1–29.

Tanne K, Tanaka E, Sakuda M. Association between mal-occlusion and temporomandibular disorders in ortho-dontic patients before treatment. J Orofac Pain. 1993;7(2):156–62.

Travell J, Rinzler SH. The myofascial genesis of pain.Postgrad Med J. 1952;11:425.

Travell JG, Simons DG. Myofascial pain and dysfunction.Baltimore: Williams & Wilkins; 1983.

Turk DC, Rudy TE. Toward a comprehensive assessmentof chronic pain patients: a multiaxial approach. BehavRes Ther. 1987;25:237–49.

Vanderas AP. Craniomandibular dysfunction in children.J Dental Child. 1992;59:342–5.

Visscher CM, Naeije M, De Laat A, Michelotti A,Nilner M, Craane B, et al. Diagnostic accuracy oftemporomandibular disorder pain tests: a multicenterstudy. J Orofac Pain. 2009;23(2):108–14.

Wadhwa L, Utreja A, Tewari A. A study of clinical signsand symptoms of temporomandibular dysfunction insubjects with normal occlusion, untreated, and treatedmalocclusions. Am J Orthod Dentofac Orthop.1993;103(1):54–61.

Westesson PL, Kurita K, Eriksson L, KatzbergRH. Cryosectional observations of functional anatomyof the temporomandibular joint. Oral Surg Oral MedOral Pathol. 1989;68:247–55.

Westesson PL, Eriksson L, Kurita K. Temporomandibularjoint: variation of normal arthrographic anatomy. OralSurg Oral Med Oral Pathol. 1990;69(4):514–9.


Documents

Jeffrey P. Okeson and Isabel Moreno Hay - fkg.usu.ac.idfkg.usu.ac.id/images/Bahan_Kuliah/Buku_McCullough/Clinical-Evaluation-of-Orofacial... · the information collected from the