June- TMJ

[Kyle Feldman]

A 34 year old female mother of three children under 6 years old is referred from her dentist with chronic pain and intermittent clicking in her right jaw for approximately four years duration. She reports constant clicking and headaches in her head and jaw. With further questioning, she reports having anxiety and depression since she was 14 years old. Her husband works and travels often leading to her managing 90% of the household. Her family just moved to the area leaving her extended family for her husbands job leaving her without help around the house.

Let’s talk subjective first – what are 1-2 questions that you want to make sure to ask this patient to help with your differential diagnosis? Be specific about what those questions would then lead you towards in differential lists, POC, etc.

I’ve attached a great two-part review paper on TMD eval/treatment. Pay attention to the diagnosis and interventions sections.

https://pubmed.ncbi.nlm.nih.gov/24976743/
https://pubmed.ncbi.nlm.nih.gov/24976744/

We will attach another article and more questions in two weeks after this part of the discussion concludes

[David Brown]

Kyle,

I think this is a great case as I rarely see this in the clinic so having a good refresher will help immensely.

Q1. “How are you going about managing your stress with everything that you are responsible for in your everyday life? Are working with any health care professionals to manage stress? Are you exercising and getting good sleep? How does your jaw respond to stress alleviators?” I know this is more than one question, but they are all pertaining to the underlying understanding that stress can perpetuate pain in the TMJ region to getting a good understanding of daily stressors, especially in this patient’s situation, is of upmost importance.

Q2. “What side of your mouth do you find yourself chewing your food on?” Given the reports of clicking in her jaw, this sounds to me like more of an Arthralgia than a Myalgia, but I would still like to begin my differential with confirming what side she favors, if any at all, while eating. I would expect with an Arthralgia there would be an increase in the R sided symptoms with chewing food on the L side of the mouth and relief if chewing food on the R side.

[Kyle Feldman]

Great questions David

i think they are very valid and great to ask. You are placing great value in the psychosocial component of care and that is important here.

Q1- if she said she just deals with the stress and has a glass of wine at nigh to unwind, what would you do?
If she has no interest in adding a councilor or psych to her care, what would you do?

Q2- She stated she is not sure. What homework would you give her to figure this out? Do you want her to think about it? Change things?

[Kyle Feldman]

Great questions David

i think they are very valid and great to ask. You are placing great value in the psychosocial component of care and that is important here.

Q1- if she said she just deals with the stress and has a glass of wine at nigh to unwind, what would you do?
If she has no interest in adding a councilor or psych to her care, what would you do?

Q2- She stated she is not sure. What homework would you give her to figure this out? Do you want her to think about it? Change things?

[Sarah Frunzi]

Hi Kyle!

As someone who has frequent headaches of varying types, I would want to dive deeper into her headache frequency, location, duration, and any correlation with her jaw pain during headache onset. I would also want to ask how she is managing headaches where it be through medication, massage, ice/heat, etc. as this could also help tease out myofascial involvement in neighboring musculature that could be referral or if more of a cervicogenic involvement could be present, which could also be related to her jaw pain based on innervation involved.

Questions: How often are you having headaches? Can you tell me where they are located and how long you have them for? What are you doing to help with headache pain? Do you notice you have jaw pain the same time you have headaches? Also, have you had headaches for as long as you have had your jaw pain?

Sorry it wasn’t just 2 questions either, but all are related!

[Kyle Feldman]

Great idea!
Yes, looking at the headaches more may find the myofascial driver for the jaw and may treat both!!

She has base of the skull and a headache in the shape of a crown around her head
The headache also goes into her temples/forehead

[Kyle Feldman]

Great idea!
Yes, looking at the headaches more may find the myofascial driver for the jaw and may treat both!!

She has base of the skull and a headache in the shape of a crown around her head
The headache also goes into her temples/forehead

[David Brown]

Kyle,

Q1) If she feels as though a glass of wine at night (as long as it is not in excess) can sufficiently mitigate her stress I wouldn’t necessarily discourage that. However, I would explain how stress can perpetuate her TMJ sx and discuss how counseling can potentially help her stress and this her TMJ pain. I would also advocate the positive effects non-specific exercise can have such as walking or running on mental wellness and discuss strategies on how to implement that into her busy life.

Q2) I would encourage her to think about what side she naturally chews on and if she ever varies the side of her mouth in which she chews on. If she finds it is constant left sided chewing maybe try the right side and see what affects that has on her sx.

[Kyle Feldman]

David- great points. we do not have to condone these types of additions that could lead to other issues.
But I recently had a patient using medical marijuana and reported 80% improved symptoms. I did not say that was the answer, but I also did not say stop either.

Yes, good idea of chewing
that made a big difference for her

[Laura Thornton]

Nice initial discussion guys!

Interesting and important points about the relationship between her jaw pain and headaches. I also appreciate the point about the chewing from side to side – great idea to determine joint compressive load sensitivity!

So we’ve honed in on our differential list so far:
Myogenic pain
Arthrogenic pain
Cervicogenic pain

Let’s dive deeper into subjective history – what else would you want to know that may help to differentiate between myogenic vs. arthrogenic pain referral?

[David Brown]

Laura,

Thanks so much for organizing our thoughts into 3 different differentials. When it comes to ruling in arthrogenic pain, I think inquiring about mechanical symptoms such as locking, catching, clunking, etc of the involved side of the jaw would help me gauge to what extent the joint might be involved. Also, with arthrogenic pain, oftentimes there will be ipsilateral lateral excursion of the jaw to the involved side with opening due to difficulty with movement of the involved side’s TMJ. When it comes to myogenic pain, I would expect less mechanical symptoms and more pain in the region of the master of the temporalis muscles with opening and closing of the jaw.

[Kyle Feldman]

Great points both of you

so with this case, and with most cases, it is not 100% myo or artho.

Her driver based on the treatment plan was myogenic but once we hit a plateau, the joint treatment and motor control training allowed for more progress.

The key points that Laura is trying to present is that we NEED to be thinking pain drivers and differentials instead of just treating impairments!

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