These reports will focus on two patients with two very different TMD problems. The importance of making a clear and accurate diagnosis is essential to the success of treatment. If we can measure something it becomes a fact, without measurement, it is most often just an opinion. The use of the BioPAK Measurement System* as an aid in diagnosing TMD and for measuring the outcome of treatment can be appreciated from the following two case examples. The value of combining the information from the radiographs, the clinical exam and history with the findings of the BioPAK will also become apparent. The conservative and reversible nature of treatment that is possible when we achieve a comprehensive diagnosis will also be demonstrated.
CASE 1 (L.J.) (Figs. 1-6)
Subjective findings
* L.J. is a healthy 44 year-old female with a non-contributory medical history. She was examined by her family M.D. and ENT. All tests within normal limits.
* Her chief complaints were jaw locking, jaw clicking, jaw noises, jaw pain and headaches.
* L.J. indicated symptoms of jaw pain on the left while chewing, jaw popping, jaw locking open, teeth grinding, pain behind the ear and pain in front of the ear.
* She states the condition first occurred 12 years ago and was related to an injury sustained to the face.
* She describes the pain as “Brain Pain”.
* The original pain was on the right side of the jaw/head. Most recently moved to the left and now interferes with her day-to-day life.
Objective findings
* Mild muscle pain upon palpation of the posterior temporalis bilaterally, middle temporalis bilaterally, the right intra-auricular region, pre-auricular region bilaterally, left TM joint capsule, right superficial masseter, left stylomandibular ligament and right sternocleidomastoid.
* Moderate pain elicited in the anterior temporalis bilaterally, left intra-auricular region, left superficial masseter, left SCM, left splenius capitus, and left coronoid process.
* Severe pain was elicited in the deep masseter, occipital region, left posterior digastric, lateral pterygoid bilaterally and medial pterygoid bilaterally.
* Dental examination of the hard and soft tissues was within normal limits.
* A full radiographic workup revealed bilateral posterior/superior displacement of the condyles (Fig. 1).
* JVA and Jaw Tracker tests were performed (Figs. 2 & 3). There was a left anterior disc displacement with reduction. The right disk may be (chronically) displaced without reduction.
Assessment
* Diagnosis was an anterior disc displacement with reduction.
* Bilateral headache and facial pain.
* Bilateral myalgia.
Plan of treatment
* Treatment will be conservative in nature.
* Goals are to improve range of motion, reduce inflammation and pain and control the locking of the jaw.
Treatment
* The treatment commenced in March 2003 with the insertion of a lower orthopedic appliance to be worn all day and night except during meals.
* Patient was seen for a 2 week follow-up and reported a reduction in headaches and better jaw movement.
* At one month, all headaches have gone. No need for any pain medications. No “Brain Pain”. ROM now 49mm. Ear symptoms have subsided.
* June 2003, L.J. reports she is feeling “80 percent better”. ROM= 50mm. Reports that she is clenching more. Agreed to fabricate a night time Maxillary Deprogrammer. Inserted July 2003. Day-time appliance use reduced to 12 hours per day.
* Started with chiropractic therapy in November 2003. Daytime appliance use down to about eight hours, still uses maxillary deprogrammer at night.
* March 2004 patient placed on recall. No day-time appliance use, just night.
* Final Tomograms January 2005 (Fig. 4).
* Final Jaw Tracker and JVA (Figs. 5 & 6).
Discussion
The diagnosis of pain in the head and neck region can be very confusing. Patient L.J. is a classic example. She was examined by the medical profession namely, her family M.D. and an E.N.T. specialist. There was no apparent reason for her “brain pain” as she described it. This lead her to follow-up with her family DDS who in turn referred her to us for evaluation.
Once a complete and thorough examination was completed a tentative diagnosis was made. The radiographs provided us with an indication that there may be a TM joint/disc problem. The use of the BioPAK indicated bilateral closed lock (Fig. 7). Furthermore, by allowing the diagnosis to be even more specific (i.e. a left anterior disc displacement with reduction and a probable chronic right disk displacement without reduction), a prognosis of the outcome could be made (i.e. An anterior disc displacement has a better prognosis than a medial disc displacement or a perforated disc). The BioPAK data allows a clinician to differentiate between anterior, antero-medial and medial disk displacements with reduction.
Physical therapy and chiropractics were used to manage the muscle pain in the neck region. A multi-disciplinary approach to treatment was important with L. J.
The conservative and reversible nature of this treatment is invaluable to both the patient and doctor. For L.J. no extensive or invasive treatments were needed to maintain her in a pain free state.
CASE STUDY 2 (T.R.) (Figs. 7-15)
Subjective
* Initial exam December 2002, 38-year-old female.
* Healthy, HBP otherwise non-contributory medical history.
* History of jaw locking, one-year duration.
* Originally started seven years ago.
* Headaches, neck aches, face pain.
* Affects life, daily activities.
* One year ago locked L. side.
* Sees Chiropractor, adj. Do not hold.
* Vioxx daily.
* Headaches forehead, cheek, up neck, across the front of head, pain so severe had lost time from work.
* Was in contact with doctors in Washington, DC but due to costs and risks of surgery, did not proceed with treatment. Wanted conservative treatment first.
Objective
* BioPAK indicates bilateral closed lock (Figs. 7 & 8).
* No joint noises and limited opening all suggesting bilateral closed lock.
* Examination revealed severe jaw pain, muscle pain in head and neck, muscles of mastication.
* Combination of intra-capsular and extra-capsular problems.
* Verification of anterior disc displacement (Fig. 14) without reduction with MRI and Tomo’s of joints.
* Dentally and Skeletally CL III open bite.
Assessment
* Bilateral DD without Reduction.
* Facial pain.
* Myositis.
* Capsulitis.
* Temporal Tendonitis.
* Headache.
Plan
* Insertion of Lower Pivot appliance, 4-6 weeks.
* Insertion of Lower MORA , 4-9 months.
* Maxillary deprogrammer to be worn at night (sleep) to control parafunctional habits.
* Chiropractics.
* Physiotherapy.
* Therapeutic and Diagnostic Injections.
* Referral to Chronic Pain Centre for management of Pain symptoms.
* PIVOT inserted December 19, 2002.
* Patient reports in February 2003, that she “hasn’t felt this good in years”.
* ROM in February 41mm no pain.
* Phase II MORA inserted March 2003.
* Spray and Stretch to relax muscles. Patient “feels great, neck is looser, can move jaw more”.
* Placed on Flexeril 10mg tid for 7-10 days.
* April 2003, sleeping great, more energy to do daily chores, right joint capsule tender to palpation. Placed on 30 minutes of Infra-Red Therapy. Improves ROM to 46mm.
* May 2003, relapse in pain. Patient had gone to Dentist and had 4 restorations placed. Jaw opened too long. She also tried more physical activity. Could not handle the work. Fit Maxillary deprogrammer (Shimbashi 28mm). Placed on Infra-Red for 30 minutes. Felt better. Referred to Pain Centre.
* June 2003–feeling better. Has localized pain to Bilateral Stylomandibular ligament areas and Temporal Tendon. Patient agreed to Diagnostic and Therapeutic Injections. Lidocaine 2% no epinephrine injected. Immediate pain relief. Spray and Stretch, ROM 50mm.
* July, August and September- no pain, ROM 50mm, right and left lateral 10mm.
* Referred for MRI.
* MRI showed recapture of disc while MORA in place.
* November–discussed treatment options. Orthodontics and orthognathic surgery, long-term appliance wear.
* Patient elected to have Arthrocentesis and continue with night-time appliance wear.
* See figures 9 & 10 for post appliance BioPak results.
* See figures 11 & 12 for post Arthrocentesis BioPak results.
* See figure 15 for post-treatment MRI.
Case summary
This case demonstrates a conservative treatment approach to treating a bilateral closed lock (anterior disc displacement without reduction). The importance of a combined treatment protocol with the medical management of the chronic pain, the involvement of the Chiropractor and the Oral Surgeon is emphasized. The patient has been placed on a follow-up schedule.
T.R. was seen for a one-year follow-up on January 13, 2005. ROM measurement was 60mm opening with a slight deflection to the left (approximately 3mm) and no pain. She continues to wear her night appliance and has had to wear her day appliance only three times since her last visit. She reports no head pain, neck pain or shoulder pain.
T.R. has decided not to proceed with any further orthodontic/orthognathic treatment at this time.
Dr. Rondeau is past president and senior certified instructor for the International Association for Orthodontics. His practice is limited to the treatment of patients with orthodontic, orthopedic and TMJ problems. Dr. Rondeau is a Diplomate of the International Board of Orthodontics. He is an editorial consultant for the International Association for Orthodontics, American Association of Functional Orthodontics and the Journal of Clinical Pediatric Dentistry.
John C. Radke is president of BioResearch Associates, Inc., Milwaukee, WI. He is a member of the International Association for Dental Research, the International Neural Network Society, the American Association for the Advancement of Science and an honorary member of the Italian Academy of Electromyography and Kinesiography.
Doug Johnson has been director of dental education at BioResearch Associates, Inc. for the past six years and has previously participated in a number of dental research projects, which he presented at the 30th General Session of the American Association for Dental Research. Mr. Johnson is also a member of the International Association for Dental Research.
*BioResearch Associates, Inc., Milwaukee, WI.
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