March – 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. Her past medical history includes clinical anxiety and depression since she was 14 years old. Her husband works and travels often leading to her managing the household 90% of the time, which she admits may be contributing to her high stress level.

Please list your initial differential diagnosis list and RANK from most likely to least likely, with relevant subjective signs/symptoms listed for each. You can also add in subjective questions you would like to ask to help with your list.Please list your initial differential diagnosis list and RANK from most likely to least likely, with relevant subjective signs/symptoms listed for each. You can also add in subjective questions you would like to ask to help with your list.

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[ebusch19]

1. Disk displacement with reduction with myogenic component
• Can you recreate your pain with pressing the muscles around the jaw? Or does massaging around the jaw help?
• Pain worse with chewing? Eating harder foods?
• Grind teeth at night? pain worse when stressed?
• Is pain flared up with increased anxiety and depression?

2. Disk displacement without reduction
• Joint locking?

3. Arthrogenic TMD
• Movement restriction?
• Grinding audible noise?

4. Upper cervical referral
• Pain with neck movements? Headache start in the back of the head and radiate to the forehead or behind the eye?

5. Visceral referral: heart
• Pain with exertion? SOB? Chest pain?

6. CAD
• Dizziness? Double vision? Difficulty speaking or swallowing? Sudden falls or feeling of loss of balance? N/T? nausea? Difficulty walking?

[iwhitney]

1. Anterior disc displacement with reduction: chronic jaw symptoms with intermittent clicking, age, gender, PMHx of depression/anxiety, high stress.
-Are your symptoms unilateral or bilateral?
-When do you notice the clicking in your jaw? What activities/movements are associated with it?
-Do you ever have difficulty opening/closing your mouth or feel like somethings blocking you?
-Any change in your dental history over the last 4 years? (e.g. invisalign, night guard, surgeries, braces/retainers, etc.)
-Do you notice a relationship between high stress and increased jaw symptoms?

2. Temporomandibular myofascial pain syndrome: chronic headaches/jaw symptoms, high stress life, PMHx anxiety/depression.
-Do you have a history of teeth grinding, clenching (bruxism)?
-Do you have pain with eating, especially hard foods?
-Do you have tenderness and pain on the side of your head, jaw, cheek?
-Do you feel there is a relationship between high levels of stress and increased jaw pain/headaches?

3. Cervicogenic HA: chronic headaches, high stress.
-Is your headache and jaw pain aggravated with neck movements?
-Do you have increased headaches/jaw pain with prolonged static positioning?
-Does your pain start in your head and radiate to your jaw? Which comes first?

4. Upper Cervical Ligamentous Disruption: chronic head/jaw pain, clicking
-History of MVA or neck trauma?
-Head/jaw pain with neck movements?
-PMH of RA? Bilateral joint pain/stiffness? Stiffness in AM >30 min?
-Feels like you have a lump in your throat? Feel like you have to constantly swallow?
-Numbness/tingling, pins/needles in head, jaw, neck, or UEs?

5. Cervical Arterial Dissection: HA, jaw symptoms
-5 D’s And 3 N’s
-Location/description of HA – aura migraine, tension, cluster differential?
-Are your recent headaches familiar or unlike any other you’ve had?
-History of trauma?
-PMHx of HTN, DM, HLD, CT disorder?
-Are you a smoker?

[cmocarroll]

Ant disc displacement with reduction; joint clicking,
Q: Are you able to fully open and close your mouth? Do you clench or grind your teeth? Have you ever worn a night guard or retainer?
If ROM restricted, would consider anterior disc displacement without reduction; but this is less likely due to the constant clicking.

Capsulitis; stress, duration of symptoms
Do you have pain at rest? Are you able to fully open and close your mouth? Is the TMJ painful to touch?

OA of TMJ; four year duration, would expect more grinding than clicking
Q: Are you able to fully open and close your mouth? Do you notice any grinding at the TMJ?

Rheumatoid Arthritis; age, female,
Do you have additional B joint pain? History of RA in family? (+) rheum factor?

All of the above may have myogenic contribution due HA in head/jaw and stress, anxiety and depression component.
All above likely have cervical component due to HAs into head and jaw pain.

[Kyle Feldman]

Great differentials and questions everyone

As you ask the questions and change your differentials, make sure that you are changing the order of the ranking for your hypothesis.
We see residents asking the right questions but the thinking of diagnosis doesn’t seem to change.

More questions:
With every patient, we need to consider contributions from any psychological or social aspects that might impact our care or response to treatment. Starting with a yellow flag screening tool is an excellent place to start evaluating these components. What screening tools could you utilize with this patient?

If there was a higher psychological component in her case, how would your plan of care change?

[Author]

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