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Les dysfonctions temporo-mandibulaires - Diagnostic & Bilan
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As we have just seen, temporomandibular dysfunctions (TMJ) represent a set of complex disorders affecting the masticatory muscles, the temporomandibular joints (TMJ) and the surrounding structures. Their multifactorial etiology and clinical variability pose significant challenges in terms of diagnosis and management. In this context, physiotherapy plays a crucial role in offering accurate diagnostic approaches and targeted therapeutic interventions. In this section, we will see the methods of diagnosing DTM in physiotherapy, in our private practices.
We can't start this diagnostic part without talking about DC/TMD. This is THE classification of the diagnostic criteria for DTM. It is a very widely used system to diagnose temporomandibular disorders and assess their severity as shown by List & Jensen in 2017. It was developed to standardize the diagnostic process and facilitate clinical and epidemiological research in the field of DTM. This classification is based on a multidimensional approach, taking into account both clinical symptoms and the results of clinical and radiographic examinations.
It should be noted that the DC/TMD classification is an ever-evolving clinical and research tool, with regular updates to reflect advances in the understanding and management of DTMs. Familiarity with the latest guidelines will be required to ensure appropriate assessment and management of patients.
In this classification we find a 91-page clinical examination protocol that we will summarize and simplify in this presentation. The aim of this protocol is to provide an effective and comprehensive procedure for resolving reliability and validity issues. However, it is important to specify that it is a tool developed by (and for) teams composed of scientific experts, researchers and doctors; its use may require some adaptations for practice in a physiotherapy office. In this presentation, I would therefore like to share with you my experience and my liberties concerning certain practices.
The clinical interview is a critical step in gaining a comprehensive and holistic understanding of the patient, which is essential for accurate diagnosis, effective treatment planning, and building a trusting therapeutic relationship.
First, let the patient explain to us his reasons for consultations. It is not uncommon to be surprised by the precision of the information and feelings described by the patient concerning the mechanics of their pain. This first step allows us to know the predominant clinical signs: pain, joint noises, amplitude limitations, location of clinical signs. Take advantage of this time of expression to appreciate the patient's gestures, posture, speech, and parafunctions.
In a second step, we will guide the patient with specific questions in order to obtain a complete evaluation of the DTM, allowing for an effective and personalized treatment.
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1) Pain
The pain assessment assesses the following parameters: duration, location, intensity.
- How long has the pain been there? The DC/TMD is particularly interested in pain âwithin the last 30 daysâ which is considered to be more clinically relevant. Given the therapeutic error that is still present in the management of DTM, we will have to be attentive in the office to pains that are very often present for much longer. We will try to focus the patient on their feelings over the last 30 days, taking into account the evolution since the onset of pain.
- What is its location: pretracheal (near tragus), pseudo-otalgic, pseudootalgic, dental, sinus, retro-orbital, temporal, periauricular, frontal, occipital, hemifacial, hemifacial, pseudootalgic, angulomandibular, unilateral or bilateral regions,
- Is it a muscle pain? more articular?
- What is the type of pain: throbbing, dull, dull, acute, paroxysmal, neuralgic,
- What is its frequency: occasional (stress) or constant,
- What is the rhythm and evolution of pain: daytime, morning, late in the day, or nocturnal,
- Are there any triggering factors: yawning, chewing, speaking, normal, forced or prolonged oral opening, spontaneously
- The circumstances of occurrence: stress or trauma,
- Intensity: rated from 0 to 10 using a visual analog scale, which will allow us to have a precise starting point.
The more details we have about this pain, the more comparison we will have for future consultations. DTMs are multifactorial pathologies; it is not always easy for the patient to compare his genes from one session to another, depending on his psycho-social situation. We must be able to rely on precise and detailed answers to observe an anatomical improvement despite emotional difficulties, for example.
If you want more details about orofacial pain you will find theInternational Classification of Orofacial Pain, 1st edition (ICOP) published in January 2020, which is described as a âcomprehensive manual for research and diagnosisâ and which is intended to be âparticularly useful when the diagnosis is uncertainâ.
2) Mechanical disorders
The assessment of mechanical disorders looks for several elements:
- Joint noises or gnathosonies = clicks, crackles, screams.
Since when have they been present? Are they unilateral or bilateral (rare). What are the circumstances of occurrence: are they early or late when opening the mouth, yawning or closing the mouth, when chewing? Are they accompanied by a feeling of blockage when opening or closing your mouth? Â
Slams are characteristic of a reducible disc dislocation. They occur at the opening, when the condyle recaptures the articular disc, placed in an excessively anterior position; then at the closure when the condyle passes back to the back of the disc. The click corresponds to the passage of the posterior bulge of the articular disc. Crepitations, such as wet sand, are characteristic of morphological modifications of articular surfaces, as described by Duminil G in an article in 2013.
- Mandibular kinetics = oral opening. It can be deviated, bayonet-like, sinusoidal or arciform. Is it fluid or with a jump? A jump in buccal opening or closing, unilateral or bilateral.
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- Articular amplitudes = oral opening, right & left diduction, propulsion. Is the mouth opening in the axis, with a deviation then a refocusing, a simple deviation? Are the deductions equivalent? Is propulsion sufficient? The precise evaluation (with measurements) of the mechanics of the jaw will be done during the mobility examination in part II. During the interview, jaw movements are observed to note the initial elements that the patient describes as important in relation to the initial complaint.
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3) Muscle signs
The muscular evaluation is carried out in a second step during palpation. However, during the clinical interview we can already ask the patient if he feels tension, at the level of the masticatory muscles (masseters, mainly temporal) but also at the level of the muscles of the cervical spine.
The patient can specify that he grits his teeth voluntarily, that it is a habit. He can also simply squeeze when he is concentrated, when he is doing a physical activity or even when he is only stressed... or in a totally involuntary and almost unconscious way.
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4) Parafunctions and harmful habits
The assessment and in particular the interview can highlight parafunctions and harmful habits that can impact the care. Some of these habits are not easy to observe or even difficult for the patient to admit. Our questions may surprise and seem irrelevant, but we must explain to the patient that we use our mouth a lot on a daily basis, sometimes without realizing it, but that any action, too repeated or not, can have a negative impact on TMJ and tends to maintain dysfunctions.
Oral tics are often present and important to detect from the start: biting lips, fingers or objects, onychophagia (biting nails or skin), chewing gum, chewing gum, chewing gum, chewing gum, chewing gum, chewing of the tongue or the mucous membrane of the jugual mucosa.
Thumb or tongue suction should be noted; it may still be present in adult patients, more or less easy to admit.
Bruxism: it can be centered, eccentric, daytime or nocturnal.
Chewing: if it is not alternating bilateral (unilateral, ineffective or absent) it can create muscular asymmetries.
Positional habits: computer, video games, wind instruments or violin.
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5) Other events
Other manifestations may be encountered during the assessment such as otological signs (tinnitus, ringing, plugged ear sensation) or ocular convergence disorders, tension headaches, dizziness, neck pain, dizziness, neck pain, stress or even an unstable emotional state... All details that may be related to DTM or influence treatment. Let's write them down to follow their evolution in parallel with our care.
We will also seek to collect other more general information that may also impact ATM or psychosocial spheres:
- has the patient already had previous treatments for this problem?
- did the patient have orthodontic treatment, during growth or as an adult? Was it long, painful? Have the results changed?
- is there a traumatic history (accidents, surgery, surgery, intubation, falling on horse/bike...)?
- Does the patient practice sports? Some sports will have a greater impact on TMJ than others (boxing, swimming (almost exclusive mouth breathing))
- were cervical manipulations done?
- what is the patient's profession? A professor who talks all day will not have the same use of his ATM as a computer programmer patient working from home, as well as a musician patient (wind or string player, violinist in particular). Isabelle Breton's study?
Numerous studies (citation) have demonstrated the link between poor sleep and the onset of chronic pain and DTM. Taking an interest in your patient's sleep can be done simply by asking him how he feels about the quality of his sleep, his state of fatigue when he wakes up and during the day, or by using reference questionnaires, common to doctors specializing in sleep.
- For sleep quality: the Pittsburgh Index (PSQI, Pittsburgh Sleep Quality Index): makes it possible to assess the quality of sleep in general.âš
- the insomnia severity index (ISI, InsomniaSeverityIndex).
- the Epworth Sleepiness Scale (ESS, Epworth Sleepiness Scale).
- the Berlin questionnaire to screen them for the risks of SAHOS (hypopnea sleep apnea syndrome). This questionnaire does not make it possible to make a diagnosis, but makes it possible to classify a risk and to assess the need to perform a polysomnography.
You can find these various tests on the site âMorpheus networkâ, as well as a fairly comprehensive questionnaire that includes numerous items from the various indexes, scales and questionnaires mentioned above.
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Thanks to all these questions you now have a better overview of the general condition of your patient. The stress to which the patient is exposed (in professional but also personal life) and its management (sport, meditation, psychological care...) are important points. As already mentioned, numerous studies have proven the important link between DTMs and psychosocial factors. Simply put, a depressed, stressed or poorly understood patient will have a longer rehabilitation and a later recovery.
To go further in the analysis of these psychosocial factors you can refer to part V of this module.
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6) Orofacial praxies and breathing
The assessment of orofacial praxies explores language, lips, and ventilation. It is halfway between the clinical interview and the clinical examination.
The objective is to highlight possible dyspraxias that would have a negative impact on DTMs.
Isabelle Breton explains the link between posture, dyspraxia and DTM in two articles published in 2016. In simplified terms, if the patient has oral breathing, his tongue will be in a low position, therefore less toned, his lips will be ajar (also less tonic) and his jaw will have no other holding force than that of the masticatory muscles. The lack of lip and lingual tone will increase the work of the muscles of the cervical spine and impact its posture during the day but also at night. This creates more tension in the ATM with the risk of compression in the joint. âA prolonged posture in tilting the mandible and in cervical extension leads to united or bilateral shortening of the digastric muscles and of the cervical extensor muscles, which causes a united or bilateral increase in pressure at the level of the ATMâ.
We will observe the patient's breathing and then we will evaluate the language, his resting position, his strength, his mobility, his coordination, his control and his functions (swallowing, phonation, chewing). The tongue is the central pillar of the mouth, if it does not fulfill its functions the masticatory and cervical spine muscles will have to compensate.
â Swallowing: the patient is asked to swallow his saliva, nothing should move.
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â Chewing: is chewing effective and unilateral alternating. The patient can be particularly slow (always the last one at the table = ineffective language) or on the contrary very fast (tendency to swallow = language that does not work)
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â Phonation: have certain sounds repeated (palatine sounds âLA-NA-DA-TAâ, the tongue must touch the palate) without the tongue getting between the dental arches.
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II) Clinical examination
â1) Muscle exam
Muscle assessment is done by palpation of the muscles in search of tensions and contractures. We study exoboral and endobuccal muscles (masseters, temporal, medial and lateral pterygoid, sternocleidomastoid, upper trapezius and deep cervical muscles). The aim is to locate the pain and note its intensity. Schimann & cie, in their summary of the DC/TMD published in 2016, specify that palpation must include at least the masseters and the temporals. The other masticatory muscles may be more difficult to palpate and the results of their palpation remain unreliable according to some studies such as Conti & cie in 2008.
Palpationis done muscle at rest and then contracted muscle (the patient is asked to contract: âgrit your teethâ). Finally, palpation is done by passively stretching the muscle. We always compare the two sides of the face. The pressure is firm and lasts 1 to 2 seconds. Palpation specifies the location of the pain, the state of sensitivity or pain, of contracture or hypertrophy of the muscle. We can find different muscular states that can create imbalances: myalgic cords often indicate hypercontractility (spasm), hypocontractility (weak contraction compared to the opposite side), delayed contraction or even fibrillations. The patient is asked to quantify their pain on the EVA scale. We use this analog scale to compare the sensitivity from one session to another or after a few sessions before reviewing the prescriber for example.
Attention, in case of pain, you should ask the patient if there is a similarity between the pain of palpation and the painful symptom linked to the reason for consultation.
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2) Joint exam
Here we are looking for joint noises, gnathosonies.
The click may be a sign of reducible disc disunion (DDR) or subluxation.
Crackling sounds indicate joint damage. They can mean an old irreducible disc disunion (DDI) or a degenerative disease.
Sand screeching or noise is a sign of osteoarthritis.
To best objectify the examination requires palpation in relation to the joint, the patient is then lying down, the palpation is bilateral and symmetric. The patient makes OB/OF series and lateral movements. The use of a stethoscope is possible but not mandatory. We are looking to assess the synchronous and symmetric nature or the differences that there may be between the two ATM. Is a jump observed? If yes, to what degree does OB/FB occur? Is there a snapping or a crackling sound?
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3) Mobility review
The mouth opening:
We measure the buccal opening using a caliper, its normal amplitude is 40 mm, +/- 12mm. It is normally straight.
In DTM, dyskinesias are very common. They are studied using the superior and inferior inter-incisal points (i.e. the reference point between the two maxillary and mandibular incisors) as a reference point, when they are well aligned in the occlusive position.
There are various possible cases when it comes to mouth opening:
â Trajectory of the rectilinear lower inter-incisal point: straight vertical trajectory that can be traced during the OB between the two inter-incisal points.
If it is sagittal rectilinear it is normal OB.
If it is rectilinear but with a synchronous bilateral jump and a normal amplitude, it is a bilateral and synchronous DDR.
If the movement is blocked with a reduced rectilinear opening (both condyles are blocked) it is a bilateral DDI or a bilateral muscular contracture.
â Trajectory of the lower inter-incisal point deviated (laterodeviation):
If the trajectory is deviated without jumping, with limitation of the OB (LOB): unilateral DDI or unilateral muscular dysfunction/pain (unilateral severe contracture). We will ask the patient if there is a history of snapping.
If the trajectory is diverted with bilateral jumps (on one side then on the other) it is an asynchronous DDR.
If the trajectory is deviated with a unilateral jump (bayonet movement) it is a unilateral DDR.
We will detail the disunions in Part III.
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Propulsion:
We ask the patient to move their lower jaw forward. It is also measured by caliper, between the vestibular face (face of the tooth located at the outer part of the dental arch, in contact with the cheeks and lips) of the maxillary incisor and the free edge of the mandibular incisor. It is generally between 8 and 10 mm. It can be focused or deviated, painful or not, fluid or jerky.
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The diductions:
We ask the patient to leave in the occlusion position and then to shift his mandible to the right and then to the left. The amplitude is measured between the 2 inter-incisal points when they collide, otherwise draw the median vertical line between the maxilla and the mandible. On average, the diductions are 4 to 5 mm. They may be symmetric or unequal. One side can be simpler, more comfortable, more mobile.
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In the clinical examination of DTMs we sometimes end up with cases where it can be difficult to tell the difference between muscular and joint disorders, especially if there is no joint noise. Clinical tests can then help us.
4. Clinical tests
There are several clinical tests to differentiate muscle and joint components.
Krogh-Poulsen test:
The bite test is carried out using a wooden stick or three tongue straps. The patient is made to bite on this element on one side, in the molar sector. The bite causes an increase in pressure in the contralateral joint and a decrease in this pressure in the ipsilateral joint.
The relief of pain in the joint on the tested side is a pathognomonic sign of joint pathology.
On the contrary, the increase in pain on the side of the bite is a sign of a pathology of muscular origin.
If the bite causes pain on the side opposite to the bite, it is a sign of intracapsular inflammation.
This is the most used test, it was described by Cazals G and Fleiter B. in 2017.
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Test to compare active and passive movements:
We can test the OB and the FB passively and actively.
A passive, painless and active painful movement will lead to muscular damage.
A painful passive and active movement will be a sign of joint damage.â
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Forced opening elastic strength test:
âThis test is rarely performed in general, even more so when the patient is very painful.
At maximum opening, the practitioner exerts digital support on the mandibular incisors.
- if the increase in the maximum opening by 1 to 2 mm is possible without pain the ATM seems healthy.
- if there is a strong resistance, the limitation is of joint origin.
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5. Additional exams
Radiography:â
A panorama makes it possible to visualize morphological or structural anomalies (such as a small condyle or an asymmetry of the mandibular branches). It can also allow us to see craniofacial asymmetries (hypo- or hyperplasia of the condyle, neck, or mandibular branch), fractures, or unusual shapes. The joint disc cannot be seen with this test.
Axiography:â
The axiograph is a measuring instrument that allows the graphic recording of the movements of the mandibular condyle. It makes it possible to follow the mandibular excursion in the various planes of space. The condylo-disc kinematics is then visualized in the movements of opening, closing and propulsion essentially. Axiography is useful for the characterization of joint mechanical disorders but it does not make it possible to make a diagnosis on its own. Today, it is much less used than imagery.
Tomography:
It makes it possible to visualize the joint space (closed mouth and open mouth), the morphological and structural anomalies of hard tissues (fractures, hypo or hyperplasias) and the kinematics: open mouth and closed mouth. The anatomical images in this exam lack precision compared to those obtained by a CT scan or an MRI.
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Computed tomography or CT scan:
The scanner makes it possible to visualize morphological and structural alterations, skeletal anomalies as well as mandibular kinematics. This examination makes it possible to analyze the joint space but is less effective than MRI for the analysis of soft tissue.
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Cone Beam:
It makes it possible to visualize a possible morphological evaluation, mandibular kinematics and the surface condition of the condyles, wear or fracture.
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MRI: Nuclear magnetic resonance imaging:
An MRI is the only exam that visualizes soft tissue and the disc. Mandibular kinematics and morphological and structural alterations can also be observed. A study conducted by Ahmad et al. in 2018 demonstrated the effectiveness of MRI in evaluating the anatomical structures of the ATM, allowing accurate visualization of the articular discs and surrounding tissue. It is really the radiological examination of choice in case of dysfunctions of the manducatory apparatus of joint origin. It will be necessary to make different cuts at different degrees of OB (mouth closed, mouth half open and mouth completely open) to observe the course of the articular disc.
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Not all patients who arrive at the office have necessarily had an additional examination. It depends a lot on the prescriber and it is not a problem to carry out our assessment and start our rehabilitation. If, despite well-conducted conservative treatment, the patient does not experience improvement, an additional examination may be useful. In addition, we remember that there are numerous differential diagnoses in the context of DTMs. If you are in doubt and the results of care are not satisfactory, imaging will eliminate other causes of pain that may not respond to physiotherapy treatment.
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III) The various DTMs
We saw in the first part that a group of experts had, thanks to the RDC/TMD, classified simple and complex DTMs into 4 groups. Here we will detail group I DTM, joint disorders and more specifically, condylodiscal disunions, a category that is often encountered in the office.
Small details: When intra-articular pressures increase excessively, the auriculo-temporal nerve is excited, causing a reflex contracture of the lateral pterygoid muscle. This spasm radiates throughout the masticatory muscles, causing a vicious cycle of joint compression. During a disc disunion, which may or may not be reduced, there is a stretching or even a rupture of the posterior meniscal brake and the posterior meniscal ligament. As these two structures are innervated, their deterioration is the cause of pain that self-maintains reflexively.
The FARRAR diagram is a diagram that shows the amplitude and linearity of propulsion and lateralities, showing the different possible trajectories.
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1) DDR Reducible Disc Disunity
With the mouth closed, the disc is in anteposition with respect to the condylar head; it is recapsed at the top of the condyle during buccal opening. Snaps, jumps, or crunches may be perceived during the reduction. A history describing blockages in a closed mouth position with chewing problems excludes this diagnosis.
One or more joint noises must be present during jaw movements in the last 30 days or during the examination. During the examination, a noise must be made at least once in three during oral opening-closing movements +/- during a diduction or propulsion movement.
Note that without imaging, the sensitivity is 0.34 and the specificity is 0.92.
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2) DDR with intermittent blocking
With the mouth closed, the disc is in an anterior position with respect to the condylar head; it reduces intermittently during the OB. When the disc does not make this reduction (does not move above the head), an amplitude limitation occurs. Medial and lateral displacements may also be present. Joint noises may be described during the reduction.
Criteria stated during the interview: there must be joint noises during jaw movements in the last 30 days or on the day of the exam. Or an episode of blockage with limitation of the OB and then release of the joint. As for DDR, the examination requires joint noise that is present at least once in three times during TMJ movements.
The sensitivity is 0.38 and the specificity is 0.98 without imaging.
Imaging results depend on the condition of the joint at the time. If the blockage is present, imaging will conclude the presence of disc disunion without reduction and clinical examination will be required to mark the intermittent side of the blockage. On the other hand, if there is no blockage during imaging, it will show a reducible disunity.
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3) Irreducible Disc Disunion (DDI) with OBB limitation
With the mouth closed, the disc is in an healthy position in relation to the condylar head and there is no reduction during the OB. The disorder is associated with a persistent amplitude limitation; there is no reduction possible without surgery.
The patient describes two situations: his jaw was blocked creating a limited OB and/or a limitation of OB impacting even his ability to eat. The maximum passive OB is less than 40mm.
The sensitivity is 0.80 and the specificity is 0.97.
During an DDI the MRI will show in OIM, the posterior bulge of the disc located prior to the 11:30, and/or the intermediate zone of the disc is located anterior to the condylar head.
Attention, the presence of joint noises (for example a click when opening) does not exclude this diagnosis.
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4) DDI without OB limitation
With the mouth closed, the disc is in an anterior position with respect to the condylar head, there is no reduction during the OB and there is no amplitude limitation on the OB.
The patient describes a history of DDI with amplitude limitation that may or may not have affected the diet. The OB is normal, around 40 mm.
Without imaging, the sensitivity is 0.54 and the specificity is 0.79.
When there is a need to confirm the diagnosis, the criteria for MRI imaging are the same as during an unreduced disunion with limited oral opening.
The presence of joint noises in the OB does not exclude this diagnosis.
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A short break to go even further:
This last classification is very used but it seems that the distinction is not made between grade I (partial disco-condylar disunions with meeting) and grade II (total disco-condylar disunions with meeting) DDs: it only distinguishes between disc disunions with a meeting and disc disunions with occasional meetings and blockages. The 2017 study by Litko M. states that disco-condylar disunions can be partial or total, multidirectional, with or without âreductionâ in the open mouth position; although there is some vagueness concerning the definition of âpartialâ and âtotalâ: it is recalled that DC-TMD does not include the diagnostic category âpartial disunionâ, so that some authors do make a difference between grades I and II according to the data provided by imaging and anatomical analyses.
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Grade I â partial DDR
Structurally and MRI: The condyle head is only related to the posterior bulge of the disc in maximum intercuspid occlusion (IOM). Clinically: Presence of an early click, in the first quarter of the opening, at the time of the meeting between the condylar head and the bulge, of low intensity, without a return click and not observed in induction.
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Grade II â total DDR
Structurally and MRI: In OIM, the condyle is behind the disc. Clinically: Presence of a constant double click, when opening and closing, as well as during diduction.
IV) Differential diagnoses
There are numerous differential diagnoses. Since the first reason for consultation is usually pain, we need to keep certain pathologies in mind.
Odontalgia (dental pain) is the 2nd cause of orofacial pain. Generally, the patient who suffers from a tooth will consult a dentist as the first line. But it can happen that a cervical patient tells us about dental discomfort, which can make us think of pain referred to by a masticatory muscle. Depending on the circumstances of occurrence and the explanations given by the patient, the dental cause will have to be eliminated.
Otalgia (ear pain) may cause a patient to make an appointment. If no doctor or ENT has examined his ear and the clinical examination shows nothing, the answer may simply be pain related to the ear alone.
Patients with certain pathology/syndromes (such as rheumatoid arthritis or Ehlers Danlos syndrome) may describe TMJ pain without talking about DTM. The same goes for Horton's disease, neuralgia (V, IX or Arnold).
In our office we receive a certain number of patients with migraine or suffering from headaches (post-traumatic or cerebrovascular) who may complain of TMJ pain without this necessarily falling into the category of DTM. A migraine patient may have a real DTM in addition to these facial pains but it will require the presence of dyskinesia +/- with joint noises. In these cases, the dysfunction must be treated by taking into account the factors that trigger and aggravate migraine in order not to be deleterious.
In some rarer cases, patients suffering from orofacial pain may have morphological disorders that have not yet been objectified (condylar hypo or hyperplasia in particular). Additional examinations such as a panoramic examination may help.
Note also Eagle's syndrome, rare and very algic, it corresponds to the calcification of the stylo-hyoid ligament. And psoriasis, which sometimes has ATM as the primary location.
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V) DC/TMD Axis II
To go further in evaluating our patient, we need to talk about AXIS II.
The Axis II evaluation analyzes psychosocial factors, such as anxiety, depression, and catastrophic pain.
These factors can impact the development, progression, or maintenance of TMD symptoms. By including Axis II evaluation in the diagnosis of DTM, we can develop a comprehensive treatment plan that takes into account physical and psychosocial factors.
Various questionnaires exist to assess the condition of our patients. If you want to deepen this dimension in your sessions, here is a list of scales and questionnaires.
Psychosocial status (PHQ-4) and assessment of depression (PHQ9) and anxiety (GAD7)
Location, intensity and disability related to pain (GCPS scale, âpain drawingâ)
Functional limitations (JFLS scale)
Frequency of parafunctional oral behaviors (OBC)
EDAS-21 scale, depression, anxiety and stress in 21 questions
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We can also ask the patient a few simple questions about his stress state, his stress management, his general feeling. Depending on the answers we will be able to suggest specialized therapists to best help the patient.
Reorienting the patient is important in the management of DTM. Indeed, the impact of the patient's emotional state on these orofacial pains is very marked as shown by numerous studies before and since the creation of DC/TMD. Whether to a psychologist, a sophrologist, a yoga teacher or other, reorientation will allow the patient to better manage his emotional state, in parallel with physiotherapy care for optimum and lasting results.
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VI) Conclusion
Temporomandibular dysfunctions represent a complex set of disorders affecting the TMJ, masticatory muscles and associated structures. Their diagnosis is not always easy; we must maintain a comprehensive bio-psycho-social approach to establish an accurate diagnosis. Schiffman and his team in 2014 demonstrated that anamnesis and clinical examination are the pillars of TMD diagnosis, making it possible to gather information about the patient's symptoms, medical and dental histories, as well as to identify characteristic clinical signs. We will be able to refer to the DC/TMD clinical questionnaire as well as to the various axis II tests. We will also be able to rely on complementary examinations such as imaging. In case of doubt, about the diagnosis but also about the importance of the psycho-social context, we can re-refer to a specialist (maxillofacial surgeon, dentist, psychologist...).
Early diagnosis of TMD is of particular importance, as it allows appropriate management to be initiated quickly and the progression of symptoms to be prevented. Early intervention can also reduce the need for long-term invasive treatments.
We will discuss the various possible treatments for DTMs in part 3.
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VII) Bibliography
Asquini, G., Rushton, A., A., Pitance, L., Pitance, L., L., Heneghan, N., & Falla, D. (2021a). The effectiveness of manual therapy applied to craniomandibular structures in the treatment of temporomandibular disorders: Protocol for a systematic review. Systematic Reviews, 10(1), 70.
Breton-Torres I, Jammet P. (2016). Dysfunction of the manducatory system: Understanding and re-educating. Scientific physiotherapy, 23â25.
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