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ASSESSMENT OF THE CRANIOFACIAL PAIN PATIENT

Introduction
The purpose of this section are (1) discuss the screening and physical examination processes involved in the assessment of the craniofacial pain patient and (2) to elaborate on appropriate assessment instrumentation and appropriate diagnostic tests. In this chapter, the term craniofacial pain will be used as the collective term for extracapsular disorders of the craniofacial region as well as intracapsular disorders of the temporomandibular joint (TMJ).

Screening of the Craniofacial Pain Patient
As discussed in chapter 1, a routine screening for craniofacial pain disorders may be included in the dental examination, whether it be a comprehensive new patient examination or periodic dental evaluation. In 1990 in the Journal of the American Dental Association McNeil et al., recommended the following questions be asked as screening for temporomandibular disorders:
1. Do you have difficulty or pain, or both, when opening your mouth, as in when yawning?
2. Does your jaw get “stuck,””locked” or “go out?”
3. Do you have difficulty or pain, or both, when chewing, talking, or using your jaws?
4. Are you aware of noises in the jaw joints?
5. Do you have pain in or about the ears, temples or checks?
6. Does your bite feel uncomfortable or unusual?
7. Do you have frequent headaches?
8. Have you had a recent injury to your head, neck or jaw?
9. Have you previously been treated for a jaw joint problem? If so, when?

Note: If any one of the first three questions is answered affirmatively, the clinician should complete a comprehensive history and examination; for question four through eight, two should be answered affirmatively, and for question nine, a positive answer to two other questions (four – eight) is required to warrant further evaluation.
In addition McNeil et al., recommended that the screening examination may include the following as part of a routine dental evaluation:
1. Measure range of motion of the mandible on opening and right and left laterotrusion.
2. Palpate for preauricular TMJ tenderness.
3. Evaluate for TMJ crepitus.
4. Evaluate for TMJ clicking.
5. Palpate for tenderness in the masseter and temporalis muscles.
6. Note excessive occlusal wear, excessive tooth mobility, fremitus, or migration in the absence of periodontal disease. Also be sure to note all soft tissue alterations, for example, buccal mucosal ridging and lateral tongue scalloping.
7. Inspect symmetry and alignment of the face, jaws, and dental arches.

Note: Any positive finding for procedures one through three warrants consideration for a comprehensive history and thorough examination. Any two positive or abnormal findings for procedures four through six likewise deserve similar consideration. If procedure seven demonstrates abnormal findings and along with this observation there are two positive findings four through six then the same consideration is given.
Patients who live with chronic craniofacial pain frequently do not volunteer information about their disorder at dental appointments because rarely do they realize that these problems may be diagnosed and treated most effectively by dentist. As a result, patients may suffer for years needlessly when help is readily available.
The objective of this screening process is to detect as early as possible signs and symptoms associated with craniofacial pain disorders. If the patient’s subjective complaints and/or objective findings are significant, the screening examination becomes a precursor to a more comprehensive history and examination.

Comprehensive Evaluation

The comprehensive evaluation consists of obtaining a thorough history and performing a physical examination. In addition, if indicated, specific types of temporomadibular and craniofacial imaging may be utilized. Further, there is an array of diagnostic tests which are available to aid the clinician in arriving at an accurate diagnosis. This section will examine these four parameters of a comprehensive evaluation process: (1) History, (2) physical examination, (3) imaging and (4) additional diagnostic testing.

The patient’s lifestyle habits may be reviewed. The patient’s sleep patterns, stress and workload, as well as recreational patterns may also be noted. This may include their involvement with vocal or instrumental music, along with diet and nutrition. A postural history may be noted along with any previous diagnoses as well as the patient’s awareness of postural related or structural inadequacies.

Psychosocial History

A psychosocial screening is often of value for the craniofacial pain patient. This may be as simple as the short Life Events Questionnaire, which has been recognized as a valid and accurate assessment of stress levels in one’s life. Two more detailed, valuable and simple tests are TMJ scale and Chronic Pain Battery. Other tests used are the Beck Depression Inventory (BDI), Cornell Medical index (CDI), Minnesota Multiphasic Personality Inventory (MMPI) and the Million Behavioural Health Inventory (MBHI). The results of these types of tests can give the doctor an insight into the patient’s psychological state concerning the current chief complaints. In addition, if necessary, the results of any of these psychological screens may guide the clinician to the proper referral for further evaluation and treatment.

The TMJ scale is used for the pretreatment assessment of the craniofacial pain patient as well as a means of assessing treatment progress and treatment outcome. The test is completed entirely by the patient, thus eliminating subjective clinical bias and allowing cross practice comparison of TMD symptom severity. The TMJ scale is supported as a psychometric assessment tool and by a large body of published validation data. The tests assesses clusters of physical symptoms including joint dysfunction, pain, range of motion limitations and psychosocial symptoms including stress, psychological distress and predicts overall clinical significance of a craniofacial pain/temporomandibular disorder.

The TMJ scale, a 97-item symptom intensity inventory, was originally developed and validated in a university clinical setting and has also been validated in dozens of sites nationwide. The total normative databade for the test stands at tens of thousands of patients to date, and the published sensitivity and specificity are in the 87% to 92% range, respectively. The test compares patient scores to three databases: TMD patients, non TMD pain patients, and asymptomatic normal persons. It makes specific predictions as to whether TMD is present overall and whether is it present in several subscale areas.

The TMJ Scale Profile aids the clinician in educating the patient and helping the patient to make an informed decision regarding treatment. This graph, which is provided on the second page of the TMJ scale report, is elementary and can easily be understood by patients. It presents an excellent visual aid of the severity of the physical symptoms which the patient has provided, and provides an easy to understand rationale for the proposed treatment plan. Of equal importance, the report demonstrates the presence of emotional problems and/or stress, and can provide a useful vehicle for introducing the need for appropriate counselling or stress reduction training. Such recommendations are based on the patient’s responses to the TMJ scale and are not based on the doctor’s subjective opinion.

Post treatment testing is often conducted which can help to document the patient’s progress, assess the response to treatment, and determine when maximum medical improvement (MMI) has been reached. Such documentation is not only useful for demonstrating to the patient that he or she has made progress, but can be useful for other health care providers, insurance companies and attorneys.

Physical Examination

A thorough examination is fundamental in arriving at a proper diagnosis and, consequently, a correct treatment plan for the patient. This examination procedure may include the necessary physical examination, imaging techniques, diagnostic casts (if necessary), electrodiagnostic testing, diagnostic anesthetic blocking and pressure threshold measurements where indicated.
Because of the strong and direct biomechanical and functional interrelationship between the craniofacial and craniocervical complex, the clinician may provide a screening evaluation of the entire upper quarter neurologically, as well as biomechanically and functionally.

The etiologies of craniofacial pain disorder are often multifactorial. Dental causality is considered, but so should postural problems (especially of the head, neck and upper quadrant), psychological components, endocrine dysfunction or disease, airway compromises, genetic tendencies, pharyngeal dysphasia and other related problems. In short, these dental, structural, chemical and emotional factors may be considered as part of a thorough evaluation.

The dentist treating craniofacial pain disorders, at times, many use a multidisciplinary approach, calling on the expertise of other dental, medical, physical therapy, chiropractic, massage therapy and at times psychological specialists. When such a team approach is used, one health care provider and, preferably, the craniofacial pain doctor, may head the team. In the following discussion, components that are most frequently considered in physical evaluation are delineated. In addition various imaging and diagnostic tests have proven valuable in patients assessment are described. It must be stressed that not all areas of the physical examination, imaging or diagnostic testing are utilized for every patient. It is the prerogative of the informed clinician to determine which of the diagnostics are required for a thorough evaluation of the patient based on chief complaints and history.

Static Musculoskeletal Assessment

This evaluation involves the passive observation of the patient’s neutral (habitual) posture. If abnormalities are noted other specialists may be consulted. Included in this evaluation may be an evaluation of the head posture from both frontal and lateral perspectives. In addition, shoulder posture may be noted from both frontal and lateral positions as well as the positioning of the scapulae and clavicles. Abnormal positioning of these structures may require referral to those who manage musculoskeletal disorders.

Dynamic Musculoskeletal Assessment

This portion of the examination provides working knowledge of the patient’s ability to move normally/abnormally. Range of motion, including cervical spine movement, (Table 2.1), strength and pain with movement may be evaluated.

Table 2.1:
Cervical ranges if motion.

Cervical Ranges of Motion Normal
Forward flexion 45 degrees
Extension 45 degrees
Left lateral flexion 40 degrees
Right lateral flexion 40 degrees
Head rotation left 70-80 degrees
Head rotation right 70-80 degrees

Cranial Nerve Evaluation

Because of the strong interrelationships of the 12 cranial nerves and the multiple signs and symptoms exhibited in craniofacial pain disorders, this evaluation and its subsequent findings may very well lead clinician to a different perspective as to cause and effect relationships and recommended treatment.

Cervical Nerve Screening

The trigeminal nerve provides the motor and sensory innervations to the masticatory system. The trigeminal spinal nucleus, being intimately associated with the substantia gelatinosa of the spinal cord, descends caudally at least as far as C-8 in rats. In addition to lesser occipital and greater occipital nerves, the involvement of the overlapping neural pathways in the upper cervical spine, especially the trigeminal nerve with cervical nerves, may be a major etiological factor for craniofacial pain and pain mimicking temporomandibular disorders.
Cervical nerver screening is accomplished for C-5 through T-1. Basic evaluation will provide sensory testing for these segments. Reflex testing for C-5 through C-8 as well as observation of motor function to those structures with motor innervations from all segments provides more information.

Otoscopic Evaluation

It is not the responsibility of a dentist to diagnose otologic disorders. However, when the patient presents with symptoms of craniofacial pain or a temporomandibular disorder, which includes ear pain, preauricular pain or a combination of the two, dentist may perform at least cursory otoscopic examination. Observation of inflammation in the external ear canal, growths within the canal, as well as excessive accumulation of cerumen may be noted. In addition, it is often possible for the clinician to observe the presence of fluid behind the tympanic membrane. This may be indicative of a middle ear disorder, which may be producing pain mimicking a tremporomadibular disorder. If any findings are noted the patient may be referred to the patient’s primary care physician or an otorhinolaryngologist (ENT physician).
Muscle, Ligament and Tendon Palpation

Palpation of the muscles of the head, neck, and shoulder may be performed bilaterally. However, each side may be evaluated independently to allow the patient to react more appropriately to the pressure being applied. Uniform force and acute discrimination in evaluating the entire muscle is appropriate.
Following is a life of muscles that are often evaluated for patients requiring craniofacial pain assessments. This list is not all inclusive. Other muscles may also require evaluation as determined to be necessary by examining dentist.

Posterior Neck The trapezius muscle may be evaluated and this may include palpation of the cervical, shoulder and inner scapular areas. In addition, the semispinalis capitals, levator scapulae and splenius capitis may be examined. Frequently following trauma these muscles produce referred pain to the head.

Lateral Neck The sternocleidomastoid is evaluated from its insertion on the mastoid process though its body and into its origin including both the sterna as well as clavicular divisions.

Anterior Neck The scalenus antecus and medius may be evaluated with muscles along the anterior vertebral region including the longus coli and longus capitis. Today, with the number of people who work for extended periods at computers, myofascial dysfunction in the scalednes, by producing impingement on the brachial plexus, may cause thoracic outlet syndrome or mimic radiculopathies or carpal tunnel syndrome. Further dysfunction of the scalene may produce a forward head posture that may affect mandibular posture.

Extra Muscle and Ligaments The muscles of mastication include the temporalis, the masseter and the lateral and medical pterygoids. The sphenomandibularis and zygomandibularis are also included by some anatomists.

The temporalis is comprised of three distinct bellies: the anterior, middle and posterior. Each of these portions are palpated individually and bilaterally.

The masseter muscle includes the superficial portion, which encompasses the origin, mid-belly and insertion. This large muscle also has a well-developed, deep belly.

The evaluation may also include the medical pterygoid and it s insertion at the angle of the mandible as well as the anterior and posterior digastricts and mylohyoid. In addition the mandibular insertion of the stylomandibular ligament may be evaluated.

Intraoral Muscles The temporal tendon or insertion of the temporalis muscle is evaluated at the coronoid process tip and anterior aspect of the ramus with firm digital palpation. Tenderness of this structure is abnormal and pain generated may be misdiagnosed as a temporomandibular problem or even diagnosed as a tension-type headache.

Although the lateral pterygoid connot be directly palpated, pressure can be placed on tissue overlying the muscle to determine whether this muscle shows signs of myofascial trigger points or other muscle disorders. The lateral pterygoid muscles mar also be tested by having the patient protrude the mandible against pressure by the clinicians hand to the chin. In addition, the superior pharyngeal constrictor may be examined as it has been show to be a source of pain in the craniofacial region.
Oral Soft Tissue Examination

This portion of the physical evaluation involves examination of all soft tissue in the oral region to ensure that no occult growths or abnormalities are present, which may or may not be producing the patient’s complaint of pain.

Mandibular Range of Motion

Mandibular movement characteristics are evaluated and include maximum vertical opening. Maximum vertical opening includes interincisal distance in maximum opening and may include the addition of vertical overlap. A study by Agerberg found that normal opening is 40+mm. A position paper by Phillips et al showed that there is a subjective consensus opinion of nine organizations providing treatment for TM disorders that 40-50mm interincisal opening is normal these parameters of interincisal opening are presented as guidelines only due to the difference in study definitions as to what is a normal temporomandibular jointed person. When observing vertical opening the patient may be observed for deviation or deflection. Deviation is defined as a discursive movement (of the mandible) that ends in the centered position. Deflection is an eccentric displacement of the mandible on opening away from a centered midline path without correction to midline on full opening
Lateral and protrusive movement characteristics likewise are observed and their range of motion may be determined. It is accepted that 8+mm is normal for lateral and protrusive range for most patients. A position paper by Phillips et al, showed that there is a subjective consensus opinion of nine organizations providing treatment for TM disorders that 8-12 mm lateral movement is normal. These parameters of lateral movement are presented as guideline only due to the difference in study definitions as to what is a normal temporomandibular jointed person. An early pioneer in the area of TM disorders was Dr. William Farrar. He contended that the opening to lateral movement ratio in a healthy temporomandibular joint is generally four to one.

Temporomandibular Joint Palpation

The temporomandibular joint is palpated in an open and closed mouth position. The joints evaluated from the lateral, posterolateral as well as posterior aspect. This can be accomplished by placing the little finger into the external auditory meatus. The presence of pain and/or tenderness is noted as is the referral of pain.

Temporomandibular Joint Sounds

The temporomandibular joint may be auscultated utilizing a stethoscope and/or Doppler ultrasound device and other devices that will be discussed at the end of this chapter. The joint may be evaluated for clicking, snapping or popping in opening as well as in closing. The timing (ie., position) of the click or pop, measured in millimetres intrinsically, may be determined. These measurements should be taken during both opening and closing. In addition, the joint may be evaluated for similar sounds in both protrusive and lateral movements and the timing may not be noted as well. It may also be noted whether the joint noise occurs in a reproducible position and can be repeated through multiple provocations. Likewise, the presence of crepitation may be noted and subjectively graded by the clinician as either fine or coarse in nature.

 

Dental and Occlusal Evaluation

The dental /occlusal evaltuation may involve the oral, visual and tactile examination, but also the review of diagnostic casts and dental radiographs. Extensive review of the scientific dental literature reveals highly inconsistent with respect to occlusal abnormalities as an etiology of TMD. Yet, there are very few practicing dentists who can deny perceived associations, at times, in various forms of malocclusion and TMD symptoms. Further, these same practitioners will testify that after improvemtn of the malocclusion (regardless of the methods), in many cases patients’ symptoms have diminished. A dental and occlusal examination may be appropriate to rule out pain of odontogenic and periodontal origin.

The dental and occlusal evaluation may contain information on missing teeth, incisive overlap (both vertical overbite and horizontal overjet), interarch dental relationships such as Angle’s classification, tooth contact in habitual occlusion, and mandibular movement characteristics from habitual occlusion including the presence of working, balancing and protrusive contacts of the posterior teeth. In addition, the type of anterior guidance established in protrusive and lateral motion may be noted. Furthermore, a midline relationship in habitual occlusion, tooth mobility, open contacts and widened periodontal ligament spaces noted on radio graphs may be included. Screening films such as panoramic radiograph may be utilized to rule out the presence of any pulpal or periodontal pathosis as well as to provide a general assessment of dental health.

Imaging

The TMJ may be evaluated by radiographic imaging in maximum intercuspation, open mouth fully extended position, or any position that is warranted by the clinician to aid in diagnosis and treatment. This helps to determine the position of the condyle within the mandibular fossa and the degree of translation noted in vertical opening. Examination of the radiographs employed may also include evaluation for the presence of articular surface changes as well as any abnormal masses or findings either associated with the condyle or fossa themselves or as independent objects.

Radiography may be essential for the proper evaluation of the temporomandibular region and associated structures. All radiographs are essentially two-dimensional projections of three-dimensional objects; therefore, limitations of any single radiographic exposure must be understood. Radiographic techniques have been developed to adequately visualize that specific portion of the anatomy which is desired. No one singular technique has been shown to be all encompassing for diagnosis and, as a result, multiple projections are frequently required. Each specific projection has its advantages, disadvantages and limitations.
Listed are those projections that are most frequently utilized in the evaluation of craniofacial pain patients. Some of the indications and advantages of each procedure are detailed; however, the specific technique for achieving these projections has intentionally been omitted, since that information is adequately available in other literature.

Panoramic Radiograph

The panoramic radiograph is frequently utilized to assess gross condylar; fossa and mandibular symmetry. It is a valuable tool for general evaluation of the craniomandibular and dental structures and in assessing the osseous structures of the mandible and maxilla for pathosis.
Although panoramic radiographs produce images of the TMJ, one may get a false sense of condylar location and shape due to the position of the mandible during exposure of the radiographic film. The panoramic film is actually a transpharyngeal view, resulting in an inaccurate representation of condylar position and morphology. However, as a survey film, the panoramic may be an appropriate radiograph to be used during the process diagnosis.

Transcranial Radiography

The correct lateral transcranial radiograph may be an appropriate screening film for the routine TMJ evaluation. It demonstrates the details of the lateral pole and its relationship to the mandibular fossa. It is also valuable in assessing the degree of condylar movement relative to the fossa. Because of the superimposition of cranial structures, a distorted image is naturally produced. However, if the clinician is aware of these limitations, transcranial radiography is a valuable diagnostic tool.

Tomography

Corrected tomography is commonly used to radiographically evaluate the temporomandibular joint. The parasagittal section is valuable for evaluating the superior, anterior and posterior aspects of the condyle from the lateral to medical aspects. It affords an opportunity to vividly evauluate the joints for osseous pathosis of the condyle and fossa, as well as the specific position of the condyle within the fossa and translation of the condyles with opening movements of the mouth. Coronal and axial views may also be utilized.

Submental Vertex

The submental vertex orientation is frequently considered to be a necessary step in achieving accurate measurements in preparation for radiographs of the TMJ. It may be used to assess the condylar angles relative to the mid-sagittal plane in order to correct various projection techniques from the lateral aspects. It may also provide diagnostic information regarding condylar size, form, width and, angles as well medial and lateral pole pathosis. In addition, this projection may prove useful in evaluating symmetry of the cranium, mandible and condyles.

AP Townes View

This projection may be used to determine the relative symmetry of the maxilla and the mandible. It provides useful diagnostic information concerning the symmetry of the condyles from a medical to lateral aspect. With the mouth opened wide, the relative positioning of the odontoid process to the axis may be noted. Condylar fractures are also projected well.

Transorbital

This radiograph projection is particularly useful for detecting pathosis of the medical and lateral aspects of condyle. The superior surface of the condyle as well as the condyle neck is also displayed.

Frontal Skull

The frontal skull radiograph is similar to the Townes projection and may be taken from either the anterior or posterior. It is an excellent tool for evaluating for fractures, neoplasms and other types of pathosis related to the osseous structures, as well as cranial bone asymmetry.

Lateral Skull

The lateral skull projection is a tool which is frequently used for assessing oral facial growth and development. It is often employed for cephalometric analysis by dentist providing orthodontic care when used with a head holding device. With a slight modification and the projection focused more posteriorly, the relationship of the cervical spine, hyoird bone and skull can be evaluated. Depending on the patient’s size and should position, it is frequently found that the base of the skull, as well as cervical spine to the level of c-5-6, may easily be seen.
With the patient standing in a neutral position (also known as habitual posture) a static evaluation of the relationship of the base of occiput to C1 to the upper cervical spine can be made. There are various measurements that can be utilized to determining the angulations of the skull to the cervical spine, distances between the spinous process of C1 and the base of occiput, and the position of the hyoid bone are frequently utilized to determine postural discrepancies of the upper quarter. In addition, the clinician may assess the presence of lack of cervical lordosis. This information may be value in certain circumstances when looking at the total interrelationship of the cranio cervical complex.

Computerized Tomography (CT Scan)

A CT scan is a computer enhanced radiograph image. Computerized tomography involving 3D reconstruction is an excellent to view osseous structures, including the TMJ and the skull. These scans can also be used to determine the position of the articular disk for patients who cannot tolerate MRIs, however accuracy is less acceptable.

Arthrography

In the TMJ, arthrography is and imaging technique for evaluating disc posture that utilizes a radio-opaque contrast media injected into the superior and/or inferior joint spaces followed by radiographic imaging. The most common projection uses inferior space injection, which allows a visual field for adequately interpreting the position of the articular disc relative to the condyle. It has a major advantage of allowing a dynamic imaging process to be completed, showing the function relationship of the condyle