TMD Evaluation

Here is a sample evaluation form that we use at Freedom Physical Therapy Services.

evaluation-form-sampleClick to see larger image

Social History

Daily parafunctional activities such as smoking, bruxism, chewing gum, snoring, leaning on chin, biting nails, lip biting, clenching teeth can all cause or create symptoms. Work, household responsibilities, hobbies and/or recreational activities may involve repetitive stress and prolonged postures, e.g. computer work, that add to or exacerbate the presenting symptoms. Emotional stress can trigger nervous habits or poor postural responses, which can lead to TMJ symptoms.

Diagnostic Imaging

Diagnostic imaging helps provide added information. It is very important to make sure the clinical objective findings correlate with any diagnostic imaging. For example, disc displacement is common in non symptomatic subjects, MRI evidence of disc displacement is not considered significant unless ROM is restricted or a nonreducing disc is suspected clinically.

A Dental Panoramic Radiograph

dental-radiograph

Transcranial Xray

transcranial-xray

Tomogram

tomogram

Bone Scan

bone-scan

Cone Beam Scan

Cone Beam Scan

Images of Cone Beam Scan

Cone Beam Scan

MRI Scan Images

MRI Scan Images

Examination

This section is intended to capture the most commonly used assessment for TMD. It is not intended to be either inclusive or exclusive of assessment tools.

Observation

observation
Opening and closing of mouth: teeth normally close symmetrically, the jaw is normally centered.

observation
Alignment of teeth: note cross bite, under or over bite.

facial asymmetry
Symmetry of facial structures (eyes, nose, mouth, length of mandible)

posture
Posture: forward head posture, rounded shoulders and scapular protraction is common.

breathing pattern
Breathing pattern: diaphragmatic breathing or accessory pattern, mouth breathing, short upper lip

tongue
Tongue or lip frenulum restriction

hypermobility
Hypermobility Screen: how to assess hypermobility

rom
ROM – Range of Motion
AROM: measure from top tooth edge to bottom tooth edge
Opening and closing of mouth
Normal opening ~ 40-50 mm

Functional opening or necessary for most dental procedures ~ 36 mm or at least 2 knuckles between teeth

listening
Listening for joint noises, clicks, pops or crepitus

prostrusion of mandible

• Protrusion of mandible
Normal ~ 10 mm
• Lateral deviation of mandible
Normal ~ 10 mm
• Note asymmetrical movements, snapping, clicking, popping or jumps

deviation

Record deviations: lateral movements with return to midline

The opening pathway is altered but returns to midline, usually indicative of a disc displacement WITH reduction or could be neuromuscular dysfunction.

deflections

• Record deflections: lateral movements without return to midline

Deflections are usually associated with Disc Dislocations without reduction or a unilateral muscle restriction.

prom

Cranial Loading of Mandible provides additional valuable information

PROM: apply overpressure at the end range of AROM to assess end feel

Strength

Assess muscles of mastication, deep cervical flexors and scapular stabilizers
strength
strength
strength

Sensation

Assess upper quadrant dermatomes, C1, C2, C3, cutaneous nerve supply of the face, scalp and neck, cranial nerves V – XII
strength

Reflex Testing

jaw reflex

Joint Mobility

Long axis distraction, Medial and Lateral glide
mobility

Dynamic Loading

Load contralateral TMJ – bite on cotton roll/tongue blade
dynamic-loading

Functional Activities

Assess chewing, swallowing, coughing, and talking. Either have patient demonstrate task or ask for patient’s subjective report. Include changes the patient has made to their own diet to accommodate for their pain and dysfunction.

Pain

Determine which movements cause pain, including opening or closing of mouth, eating, yawning, biting, chewing, swallowing, speaking, or shouting. The patient may also present with headaches and cervical pain. Pain may also be present in the distribution of one of the three branches of the trigeminal nerve.

Other Complaints

complaints
These may include the feeling of fullness of the ear, tinnitus and/or vague dizziness. These symptoms are seen in approximately 33-40% of patients with TMJ and usually resolve after treatment.

Cervical Spine and Upper Quadrant Screen

Assess cervical A/PROM, muscle length including deep cervical flexors, myotomes, dermatomes and reflexes.
cervical range of motion
cervical range of motion
cervical range of motion

Upper Extremity Reflexes

reflexes

Palpation

palpation

Physical Therapy palpation of the muscles of mastication (video)

Watch this video to learn how Physical Therapist palpate or find the muscles of mastication (chewing) including the temporalis, masseter and pterygoid pair.  Treating these muscles helps reduce myofascial pain and TMJ issues.

Rocabado Synovial Pain Map

pdfView Rocabado pain map for evaluating TMD

TMJ: compare bilaterally, assess joint integrity and structural deviations
Muscles of mastication: compare bilaterally, assess for pain and/or muscle spasm
This is only a partial list of which muscles are palpated and assessed
petrygoid

Vicinity oflateral pterygoid (intraorally)
Temporalis (Externally)
insertion of temporalis (intraorally)
medial pterygoid (externally)
meidial pterygoid (internally)
masseter (externally/internally)

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