+ RDC/TMD criteria, axis I diagnoses. Group I: muscle disorders Ia. Myofascial pain: * Report of pain or ache in the jaw, temples, face, preauricular area, or inside the ear at rest or during function; * Pain reported by the subject in response to palpation of 3 of the following muscle sites (right side and left side count as a separate sites for each muscle): posterior temporalis, middle temporalis, anterior temporalis, origin of masseter, insertion of masseter, posterior mandibular region, submandibular region, lateral pterygoid area, and tendon of the temporalis; * At least one of the painful sites must be on the same side as the complaint of pain. Ib. Myofascial pain with limited opening: * Myofascial pain as defined in Ia; * Pain-free unassisted mandibular opening 40 mm; * Maximum assisted opening (passive stretch) 5 mm greater than pain-free unassisted opening. Group II: disc displacements IIa. Disc displacement with reduction: * Reciprocal clicking in TMJ (click on both vertical opening and closing that occurs at<unk>  5 mm greater interincisal distance on opening than closing and is eliminated on protrusive opening), reproducible on 2 out of 3 consecutive trials; or * Clicking in TMJ on both vertical range of motion (either opening or closing), reproducible on 2 out of 3 consecutive trials, and click during lateral excursion or protrusion, reproducible on 2 out of 3 consecutive trials. IIb. Disc displacement without reduction with limited opening: * History of significant limitation in opening; * Maximum unassisted opening 35 mm; * Passive stretch increases opening by 4 mm over maximum unassisted opening; * Contralateral excursion 7 mm or uncorrected deviation to ipsilateral side on opening; * Absence of<unk>  sound or presence of<unk>  sounds not meeting criteria for disc displacement with reduction. IIc. Disc displacement without reduction, without limited opening: * History of significant limitation of mandibular opening; * Maximum unassisted opening 35 mm; * Passive stretch increases opening by 5 mm over maximum unassisted opening; * Contralateral excursion 7 mm; * Presence of<unk>  sounds not meeting criteria for disc displacement with reduction; * In those studies allowing images, imaging conducted by either arthrography or magnetic resonance reveals disc displacement without reduction. Group III: arthralgia, osteoarthritis, osteoarthrosis IIIa. Arthralgia: * Pain in one or both<unk>  sites (lateral pole or posterior attachment) during palpation; * One or more of the following self-reports of pain: pain in the region of the<unk> , pain in the<unk>  during maximum unassisted opening, pain in the<unk>  during assisted opening, and pain in the<unk>  during lateral excursion; * For a diagnoses of simple arthralgia, coarse crepitus must be absent. IIIb. Osteoarthritis of the TMJ: * Arthralgia as defined in IIIa; * Either coarse crepitus in the<unk>  or radiologic signs of arthrosis. IIIc. Osteoarthrosis of the TMJ: * Absence of all signs of arthralgia; * Either coarse crepitus in the<unk>  or radiologic signs of arthrosis Modern digitalised panoramic X-ray devices are capable to take TMJ images, which provides information about articular fossa and condyle. Dynamics of<unk><unk>  during voluntary mouth opening and closing visualized by real-time MRI. Pain is the most common reason for people with<unk>  to seek medical advice.<unk>  noises may require auscultation with a stethoscope to detect. Clicks of the<unk>  may also be palpated, over the<unk>  itself in the preauricular region, or via a finger inserted in the external acoustic meatus, which lies directly behind the TMJ. The differential diagnosis is with degenerative<unk>  disease (e.g. osteoarthritis), rheumatoid arthritis, temporal arteritis, otitis media, parotitis, mandibular osteomyelitis, Eagle syndrome, trigeminal neuralgia, oromandibular dystonia, deafferentation pains, and psychogenic pain. Diagnostic criteria Various diagnostic systems have been described. Some consider the Research Diagnostic Criteria method the gold standard. Abbreviated to "RDC/TMD", this was first introduced in 1992 by Dworkin and LeResche in an attempt to classify<unk>  disorders by etiology and apply universal standards for research into<unk> . This method involves 2 diagnostic axes, namely axis I, the physical diagnosis, and axis II, the psychologic diagnosis. Axis I contains 3 different groups which can occur in combinations of 2 or all 3 groups, (see table). McNeill 1997 described<unk>  diagnostic criteria as follows: * Pain in muscles of mastication, the TMJ, or the periauricular area (around the ear), which is usually made worse by manipulation or function. * Asymmetric mandibular movement with or without clicking. * Limitation of mandibular movements. * Pain present for a minimum of 3 months. The International Headache Society's diagnostic criteria for "headache or facial pain attributed to<unk><unk>  disorder" is similar to the above: * A. Recurrent pain in one or more regions of the head or face fulfilling criteria C and D * B. X-ray, MRI or bone scintigraphy demonstrate TMJ disorder * C. Evidence that pain can be attributed to the TMJ disorder, based on at least one of the following: * pain is precipitated by jaw movements or chewing of hard or tough food * reduced range of or irregular jaw opening * noise from one or both TMJs during jaw movements * tenderness of the<unk>  capsule(s) of one or both TMJs * D. Headache resolves within 3 months, and does not recur, after successful treatment of the TMJ disorder Medical imaging The advantages brought about by diagnostic imaging mainly lie within diagnosing<unk>  of articular origin. Additional benefits of imaging the TMJ are as follows: * Assess the integrity of anatomical structures in suspicion of disorders * Staging the extent of any pathology * Monitoring and staging the progress of disease * Determining the effects of treatment When clinical examination alone is unable to bring sufficient detail to ascertain the state of the TMJ, imaging methods can act as an adjuvant to clinical examination in the diagnosis of<unk> . Plain radiography This method of imaging allows the visualisation of the<unk> 's mineralised areas, therefore excluding the cartilage and soft tissues. A disadvantage of plain radiography is that images are prone to superimposition from surrounding anatomical structures, thereby complicating radiographic interpretation. It was concluded that there is no evidence to support the use of plain radiography in the diagnosis of<unk>  erosions and osteophytes. It is reasonable to conclude that plain film can only be used to diagnose extensive lesions. Panoramic tomography The distortion brought about by panoramic imaging decreases its overall reliability. Data concluded from a systematic review showed that only extensive erosions and large osteophytes can be detected by panoramic imaging. Computerised tomography (CT) Studies have shown that tomography of the TMJ provided supplementary information that supersedes what is obtainable from clinical examination alone. However, the issues lies in the fact that it is impossible to determine whether certain patient groups would benefit more or less from a radiographic examination. The main indications of CT and CBCT examinations are to assess the bony components of the TMJ, specifically the location and extent of any abnormalities present. The introduction of cone beam computed tomography (CBCT) imaging allowed a lower radiation dose to patients, in comparison to conventional CT. Hintze et al. compared CBCT and CT techniques and their ability to detect morphological TMJ changes. No significant difference was concluded in terms of their diagnostic accuracy. Magnetic resonance imaging (MRI) MRI is the optimal choice for the imaging of soft tissues surrounding the TMJ. It allows three-dimensional evaluation of the axial, coronal and sagittal plane. It is the gold standard method for assessing disc position and is sensitive for intra-articular degenerative alterations. Indications for MRI are pre-auricular pain, detection of<unk>  clicking and crepitus, frequent incidents of subluxation and jaw dislocation, limited mouth opening with terminal stiffness, suspicion of neoplastic growth, and osteoarthritic symptoms. It is also useful for assessing the integrity of neural tissues, which may produce orofacial pain when compressed. MRI provides evaluation of pathology such as necrosis and oedema all without any exposure to ionizing radiation. However, there is a high cost associated with this method of imaging, due to the need for sophisticated facilities. Caution should be taken in patient selection, as MRI is contraindicated in those with claustrophobic tendencies, pacemakers and metallic heart valves, ferromagnetic foreign bodies and pregnant women. Ultrasound Where internal TMJ disorders are concerned, ultrasound (US) imaging can be a useful alternative in assessing the position of the disc While having significant diagnostic sensitivity, US has inadequate specificity when identifying osteoarthrosis. Moreover, it is not accurate enough for the diagnosis of cortical and articular disc morphology based on the findings done related to morphological alterations. However, with US, identification of effusion in individuals with inflammatory conditions associated with pain is possible and confirmed by MRI US can be a useful alternative in initial investigation of internal TMJ dysfunctions especially in MRI contraindicated individuals despite its limitations. in addition to being less costly, US provides a quick and comfortable real-time imaging without exposing the individual to ionizing radiation US is commonly assessed in the differential diagnosis of alterations of glandular and neighbouring structures, such as the TMJ and the masseter
Temporomandibular joint dysfunction
Impacted wisdom teeth
Facial nerve paralysis
Eustachian tube dysfunction
Orofacial myofunctional disorders
Barodontalgia
Ear pain
Orofacial pain