Editor’s note: “Patient History 101” is a series of four articles from Dr. Jim McKee with advice on how to obtain accurate and helpful patient history. Read his other lessons here:

Figure 1: Three common presentations of jaw joints and Piper classifications: (far left)
Figure 1: Three common presentations of jaw joints and Piper classifications: (far left) “structurally intact” - Piper 1, 2; (middle) “structurally altered at the lateral pole” - Piper 3A, 3B; and (far right) “structurally altered at the lateral and medial poles - Piper 4A, 4B, 5A, 5B.

It is important to understand that structural changes in the jaw joint can cause pain. As a profession, most dentists do not want to treat patients with jaw joint pain. Historically, we have been taught most jaw joint pain is due to hyperactive masticatory muscles from occlusal interferences (Fig. 2).

Masticatory muscles.
Figure 2: Masticatory muscles.

If this was true, then occlusal appliances would successfully treat through changing the occlusion and decreasing the hyperactivity of the muscles. Today, through 3D imaging with MRI and CBCT, it’s known that there are other sources of pain in addition to muscle hyperactivity.

In addition to pain from hyperactive masticatory muscles, pain can occur from a displaced disk. A displaced disk can impinge on tissue or displace structures resulting in pain (Fig. 3).

A displaced disk can impinge on tissue or displace structures resulting in pain.
Figure 3: A displaced disk can impinge on tissue or displace structures resulting in pain.

Pain can also occur from changes at the bone level in the condyle. The bone can erode (Fig. 4), which can cause considerable pain.

Bone can erode, which can cause considerable pain.
Figure 4: Bone can erode, which can cause considerable pain.

The bone may not develop completely and be unable to withstand the loading forces generated during normal function. (Fig. 5)

An undeveloped bone may be unable to withstand the loading forces generated during normal function.
Figure 5: An undeveloped bone may be unable to withstand the loading forces generated during normal function.

The bone can also swell in the marrow space leading to potentially high level of pain (Fig. 6).

Bone can swell in the marrow space leading to potentially high level of pain.
Figure 6: Bone can swell in the marrow space and lead to a potentially high level of pain.

In addition to pain coming from the joint, many patients can have pain originating from the upper cervical spine region that mimics joint pain. Upper cervical misalignments can cause significant pain (Fig. 7).

Upper cervical misalignments can cause significant pain.
Figure 7: Upper cervical misalignments can cause significant pain.

Lastly, a common pain source that is underestimated is sympathetically mediated pain. Dysfunction of the sympathetic nervous system, which can occur from injured joint tissue or poor sleep quality, occurs more often than generally accepted in the medical and dental professions. Patients with sympathetic system dysfunction can also present with muscle dystonia, which may help explain why some patients tend to clench or grind their teeth.

The goal of the pain history is to give insights into the condition of the temporomandibular joints. While it is not possible to diagnose the condition of the jaw joints from the history, it is possible to determine which patients may have a higher risk factor for Piper 4A/4B and 5A/5B joints.

Questions to ask about jaw joint pain

Do you have pain higher than a "5" on a 1-10 scale?

Muscle pain tends to be achier in nature and will tend to have lower pain levels compared pain coming from structural changes in the joint.

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Do you have sharp or stabbing pain?

Sharp or stabbing pain will correlate to changes at the bone level in many patients. Patients with eroded bone, small bone or edematous bone may present with sharp or stabbing pain.

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Did you have pain earlier than age 18?

Growing patients should not experience pain. If pain occurs in a growing patient, it may be prudent to assess the joint anatomy with MRI/CBCT imaging.

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Do you have headaches on a regular basis?

As Hunter wrote in 2013 in the Dental Clinics of North America, “TMD is considered the main source of pain in the orofacial region following odontogenic pain.” Many patients who present with headaches have undiagnosed joint issues. If a patient has headaches and the headaches have not been treated successfully, it would be prudent to assess the condition of the jaw joints with MRI/CBCT imaging.

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Jim McKee, D.D.S., is a member of Spear Resident Faculty.

References

Dawson PE. Functional Occlusion: from TMJ to Smile Design. St. Louis, MO: Mosby; 2007.

Cascone P, Fatone FMG, Paparo F, Arangio P, Iannetti G. Trigeminal impingement syndrome: The relationship between atypical trigeminal symptoms and antero-medial disk displacement. CRANIO®. 2010;28(3):177–180.

Bae S, Park M-S, Han J-W, Kim Y-J. Correlation between pain and degenerative bony changes on cone-beam computed tomography images of temporomandibular joints. Maxillofacial Plastic and Reconstruction Surgery. 2017;39(1):19.

Schellhas KP, Pollei SR, Wilkes CH. Pediatric internal derangements of the temporomandibular joint: Effect on facial development. American Journal of Orthodontics and Dentofacial Orthopedics. 1993;104(1):51-59.

Larheim TA. Role of Magnetic Resonance Imaging in the Clinical Diagnosis of the Temporomandibular Joint. Cells Tissues Organs. 2005;180(1):6-21.

Garcia R, Arrington JA. The Relationship Between Cervical Whiplash and Temporomandibular Joint Injuries: An MRI Study. CRANIO®. 1996;14(3):233-239.

Hooshmand H, Hashmi M. Complex Regional Pain Syndrome (RSD Syndrome): Diagnosis and Therapy-A Review of 824 Patients. Pain Digest. 1999;9:1-24.

Hunter A, Kalathingal S. Diagnostic imaging for temporomandibular disorders and orofacial pain. Dent Clin North Am. 2013;57:405–18.

Hunter A, Kalathingal S. Diagnostic Imaging for Temporomandibular Disorders and Orofacial Pain. Dental Clinics of North America. 2013;57(3):405-418.


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