Case Example: Re-testing helps patient and dentist
A 19-year-old female was suffering from TMJ pain and severe bilateral (both sides) headaches of more than three years duration. The pain started after an auto accident, and she did not have any pain before the accident. A neurologist ordered a CT scan after the accident, but it was negative. She had been treated with several medications with no success and was involved in long-term litigation with her insurance companies.
The patient was extremely anxious and nervous during the clinical examination. She was going to be married in three or four months and was concerned whether she could afford treatment.
The physical exam found extreme tenderness over the left TM joint, and in several facial muscles. Jaw opening was restricted, and a click occurs in the left TM joint at 23mm. Severe crepitus was heard in the right TM joint upon movement. The patient had recently completed orthodontic treatment and was wearing an upper removable retainer and a lower bonded retainer. All teeth were present and in good condition. X-rays were normal, showing no bony abnormalities. A diagnosis of trauma-induced bilateral disc location without reduction (the disk is misplaced and does not move upon opening(see Glossary)
The TMJ Scale was given by the dentist to corroborate these findings and to measure the severity of symptoms before treatment. All areas were elevated, except for the bite feeling off and Non-TMJ.
Repositioning splints were placed on the upper and lower teeth and the patient was instructed to wear the upper appliance only at night and the lower one during the day. She was then treated for three months with another type of splint. The patient was checked monthly, and after three months of treatment she said she felt 95-100% better. Another TMJ Scale was administered by the dentist. Some improvement was found, but many of the areas were still elevated. He immediately noted that her answers to the TMJ scale did not agree with her statement that she was much improved. When confronted with this discrepancy, she said that she was to be married in a few weeks, and had not reported some pain and teeth clenching.
Treatment continued and five weeks later she again reported a 95% improvement. She had been married, and the apartment complex she and her husband managed had been burned by an arsonist. A third TMJ Scale was given, and again the results were at odds with her verbal report. She then admitted that she needed a release from treatment to complete a settlement with her insurance carrier.
The patient was advised that it was in her best interest to finish treatment. She consented and within two months she again reported complete relief from pain. At this point she had a 55mm opening (considered normal) and no joint sounds. A final TMJ Scale report which showed most areas below significance confirmed her verbal report and she was considered completed.
Comment: This case demonstrates how the TMJ Scale can be used to monitor treatment progress, and to help the dentist and the patient to determine when treatment should be concluded.
(Published in the Journal of Clinical Orthodontics, 1991)