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A 26 year old female PhD candidate referred from her dentist with chronic pain and intermittent clicking in her right jaw for approximately two years duration. She reports recent exacerbation with dental procedure, and now experiences constant pain, but worse with chewing and eating. She also reports history of MVA with fluctuating headaches and neck spasms that she has managed pharmacologically since.
Let’s talk subjective first – what are 1-2 questions that you want to make sure to ask this patient? 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. Definitely worth a thorough read.
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To be short and sweet here are my 1-2 subjective questions I’d like to ask:
1. Pain location/locations (musculature, joint line, etc.), different from previous episodes/symptoms? -help with cervical spine involvement and its involvement potentially
2. Description of pain (tightness, sharp, clicking, locking (mechanical sx/symptoms)) and their association with aggravating activities? Change from previously? -Disc pathology (conversion from reduction to non-reduction?)versus myogenic.
(Shaffer et al. paper helpful with pt history section and table 1 info)
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1. A question to determine the patient’s severity and irritability would be very important, because it will determine how extensive my initial eval is. If the patient has really high severity and irritability, I will likely not be as aggressive during the initial eval, because I don’t want them leaving with so much pain that they can’t talk or eat afterwards. Then they won’t come back.
2. Description of pain and other symptoms. Is it just pain, or is there clicking too? Is there ROM loss, or is it normal/hypermobile? This will help with my DD and to rank my initial hypotheses.
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How about some red flag clearing questions, like questions that would give detail to items like emotional stress or instability? She’s a 26yo PhD student, so stress seems reasonable, and information on a mechanism beginning her initial pain episode can be helpful.
Assuming it’s primarily TMD mechanical, what about questions about where in the process of opening is the click and if it locks?
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I agree that questions regarding sensitivity and irritability would help guide how much we might do on initial evaluation and that red flag questions should definitely addressed here.
I am a little more curious about the MVA, how was she hit, LOC, air bags, imaging? She notes HA and neck spasms but did she have jaw symptoms prior to the accident? If so did the MVA change her sx in any way? If not did the HA and neck spasms correlate with any jaw symptoms?Secondly I would like to know a little more about the dental procedure, what was done? how long was the operation was her mouth held in an open position for an extended amount of time? Other than experiencing more constant symptoms has the intermittent clicking been changed since the procedure/ where in the chewing/eating process does the clicking occur (opening vs closing) and is it one click or two?
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1. Need to know more information regarding the MVA. So, starting with an open-ended question about the MVA. Specifically looking for 1) red flag signs and symptoms that could be related to cervical instability (Canadian C-spine, cranial nerve, and VBI) and 2) yellow flag symptoms of emotional and psychological stress. Also need to know when the MVA occurred and the details during and after the accident. Because upper cervical spine can have pain referrals into the TMJ region, it is important to try and differentiate between upper cervical and TMJ, yet it sounds like this patient could have pain generating from both areas based on the brief history.
2. I would want to know about the history of her jaw pain from the patient’s perspective, but also, I would love to hear what her dentist thought was going on in regard to her jaw pain. Specifically, I would want to know more about how her jaw pain initially started (i.e. trauma or stress), details of procedure (immobilized?), ROM loss, unilateral vs bilateral, still have clicking in jaw, and pain with compression vs opening.
My thoughts initially would be 1) disc displacement without reduction due to history of clicking but now no clicking versus a capsular hypomobility of the joint, 2) in combination with peripheral sensitization of soft tissue structures (upper cervical and local jaw musculature).
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I bet her history of MVA can be a good place to get some of this type of information… how she sought care afterward, the type of care she received, the type of care she felt like was successful or unsuccessful. More info on her experience with this event, participation in sports, and injury could be great gateways.
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I would say something along the lines of, “You have been through a lot of over the past couple of years in regards to the MVA, surgery and chronic pain – not to mention completing your PhD. I’m sure that is frustrating and challenging. Do you feel like stress affects your pain? If yes, how do you typically manage your stress?”
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I agree with both of you. I would ask her if she notices a correlation between stress and her HAs or jaw pain intensity or frequency. This would be a good gateway into how she manages stress and maybe help her understand that her chronic pain is more than just a biomechanical fault that needs fixing.
I also want to know what she does differently due to her pain. Does she avoid hard foods when her jaw hurts? Is she eating a soft/liquid diet? I want to get a sense of how much the pain interferes with her life. Is she comfortable with some pain if it doesn’t get TOO severe or irritable, or does she stop everything if there is any pain? This can help me get a sense of her fear of pain, and can lead to the start of a good pain science education discussion.
I wouldn’t have thought about asking the dentist about the procedure and about his/her opinion on the patient’s pain. I’m curious, what specifics of the dental procedure would you want to know about, and how would this help you in the diagnosis and/or treatment planning for the patient?
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Yeah, that’s a good point Jeff. Cam, are you thinking along the lines of how long the procedure was, or if he was addressing the molars vs incisors?
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Subjective Questions:
1. Pain intensity/location and comparison of symptoms to before exacerbation. Is anything new or just worsening of old symptoms? How have the clicking symptoms changed or have they? More irritabile also?
2. Relation of neck pain to her jaw symptoms? Can she correlate the pains?
3. How is her schooling affecting her symptoms? Reading, classwork, etc. Are there certain things on a day to day basis that can make her symptoms worse (either jaw or neck) other than chewing?In regards to questioning her psychosocial impacts on her symptoms, I would start by asking if she feels like her symptoms are interfering with her school life. Either from a productivity standpoint or a interpersonal standpoint due to high pain levels and difficulty eating (going out with friends). Based of this, we might get to interfering factors and better be able to understand her stress management strategies. As far as building a therapeutic alliance that encourages self-efficacy and self-management, I think it’s important to ask what she has tried other than pharmacological management. I think asking those questions and getting a sense of how active someone has been in management is a good way to get a sense of potential self-efficacy. Someone who has “tried everything under the sun” might not need as much encouragement for compliance to a home program or activity modification as someone who has been historically a passive participant in their symptom management. Obviously this isn’t the only important subjective piece, but I think asking this and then seeing how that conversation goes gives you and idea of how the PT prognosis will shape out to be.
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Jeff and Erik,
My thought with communicating with the dentist would be:
– location of procedure (soft tissues, teeth, etc)
– what was performed (hardware?)
– how long the mouth was in an opened position or immobilized closed position
– any post-op precautions or limitations
– the referral was from the dentist, so he/she must feel like this is out of his/her scope of practice, so seeing their thought process of what was going on in regards to the patient’s pain would be helpful -
I think those would be great questions to ask. Mainly because I don’t have much experience with TMJ specifically (only 2 this year) and this makes me not very confident with the various procedures that could be performed. I wouldn’t think that a dentist would refer to a PT expecting for us to “know what to do”, so I think it would be appropriate for us to ask clarifying questions to get a better idea of what to avoid/what to focus on based on what they saw during the procedure. Great list of questions Cam, especially the last one about a more specific reason for referral out of their office.
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I like the pretty immediate recognition for the value of collaboration when treating folks with TMD. It goes right along with Cam’s suggestion to call the dentist. I wonder if her initiation of TMD pain coincides with any particular part of her schooling 2 years ago? Could warrant a need for greater psych focus.
After reading this, I’d definitely ask more about parafunctions and a few more questions to help categorize the headaches. There’s a few points in what we know that makes me lean toward classifying this case as a Mastication Muscle Disorder. What do you guys think?
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Erik, good point. In reading this article, it highlights the vast differential diagnosis options there are for immediate referral, non-immediate referral, or treatment only. There are so many possibilities for the pain generator and pain intensifiers in the TMJ, so a solid subjective history is really important. To me, it makes sense that in this patient’s case, and in many others with long-lasting TMD, that there would be many yellow flags, just based on how frustrating it would be to have pain when you talk/chew, lay down, etc. The article discusses how pain-science education can decrease pain and disability in TMD patients with chronic pain. I bet a PhD candidate would really connect with this, and it would probably be easy to give her resources for her to further educate herself on this topic, and then to further discuss with her. (Speaking of: if anyone has any favorite YouTube videos or websites for this, definitely post them, as I would like to build my library of these to help use for patient education.)
Erik I partially agree with you, with the recent increase in pain being after a dental procedure and pain with eating/chewing. However I would bet that there is a large cervical spine component to this patient’s case based on her history of MVA, HAs, neck spasms, occupation (prolonged sitting…possibly postural component). Obviously there is a lot of info we don’t know to help our differential diagnosis.
Something I don’t think we’ve brought up in terms to questions for the dentist, is why was she having the procedure in the first place? Was the procedure an attempt to decrease her TMJ pain, or was it completely unrelated? Was it trying to fix an anatomical variant the dentist identified with her mouth/jaw?
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I wonder what everyone else’s thoughts are on how much centrally mediated myalgia/central sensitization is occurring with this patient? I mean she’s had multiple insults to her cervical spine and her jaw and wonder if the repetitive nociceptive input has her central system playing a role in her pain and dysfunction. I liked this article’s insight on common characteristics of central myalgia involvement (as I am not familiar with the common asterisks to look for): prolonged and uninterruptable pain, duration of greater than 1 month, pain in multiple mastication muscles, p! at rest, and p! worse with function. I think I would be definitely cautious of only treating local tissue and pushing hard to find the pain generator and assessing for the involvement of yellow flags. I also would have relaxation and pain relief interventions (like let’s get this girl a mouth guard or something) high on my list of things to address and educate on the first day. I agree though we don’t have all the information to really accurately diagnosis in my opinion.
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