Tutorial: Sad to say many dentist today do not have the skills to deal with this common patient problem called myofacial pain. Most patients that I see at our office that are refered to me for “TMJ” actually do not have tempromandibular dysfunction (TMD) but instead have myofacial pain. I’m always amused when someone tells me they have TMJ. This to me is like telling me they have elbow. Everyone has actually two TMJ’s and we need to educate the population (including many dentists) to call it what it is, TMD.
This note has been created and modified over the years to “cookbook” through a long and extensive examination to determine if the patient’s discomfort is TMD or Myofacial Pain. It involves health history aimed specifically at the mouth, physically palpating muscle groups, hard/soft tissues, and information I get from the TekScan (T-scan) and Joint Vibration Analysis (JVA).
Below is the actual note code that I use as an outline for my detailed/extensive examination for Myofacial pain:
EXAMINATION: Patient’s CC is discomfort in joint(s)/facial muscles.<HlthHx> <Race> <PrevConsult> <splint> <Habits> <Smoker> <OralTabacco> <Alcohol> <menstral> <headache> <sleep> <snore> <Trauma> <restoration> TMJ EVALUATION: <Right> <Click> <Ligamentitis> <Capsulitis> <MedPt> <Temporalis> <Masseter> <SCM> <digastric> <splenius> <trapezius> <Translation><Left> <Click> <Ligamentitis> <Capsulitis> <MedPt> <Temporalis> <Masseter> <SCM> <digastric> <splenius> <trapezius> <Translation>Maximum mouth opening <MaxOpen>mm, <Deviation> <Midline> <OverBite> <OverJet> <Diag Cast> <CrossBite> <AnglesRt> <AnglesLt> <Perio> <SoftTissue> <Asymmetry> <FMA> <Skeletal> DIAGNOSIS: The patient was informed that I feel they have myofacial pain syndrome. The cause(s) are many and can be brought on by stress, clenching, bruxing, occlusal trauma or other known and unknown factors. TREATMENT: At this time I am prescribing a NTI to be worn at night and/or during painful events. The patient is further informed that after stablization with splint therapy that I further recommend a complete exam with the Joint Vibration Analysis and TekScan to find out if occlusal trauma is the continued source of their discomfort. Risks, benefits and alternative discussed.Next Visit: <Next Visit>
These are two screen shots of the same note, just couldn’t get them both in the same screen shot.
Once you push the “OK” button the below is entered into the patient’s chart and can be added to and editing as you see fit.
EXAMINATION Patient’s CC is discomfort in joint(s)/facial muscles.Reviewed health history, Patient’s races is caucasian, Pt. has had previous OS consult, Past History of Splint Therapy. History of Bruxing, Smoker, Oral Tabacco user, Alcohol drinker, Patient on her menstral cycle, Headaches, Difficulty Sleeping, History of Snoring, Automobile accident 3 years ago. History of extensive restorative,
TMJ EVALUATION
Right: Click/Pop, Ligamentitis, Capsulitis, Medial Pterygoid muscle TENDER, Temporalis muscle is normal, Masseter belly TENDER, Sternocleidomastoid muscle normal, Digastric Muscle normal, Splenius Capitis Muscle normal, Trapezius Muscle normal,
Left: Click/Pop, Ligamentitis, Capsulitis, Medial Pterygoid muscle normal, Temporalis muscle is normal, Masseter belly TENDER, Sternocleidomastoid muscle normal, Digastric Muscle normal, Splenius Capitis Muscle normal, Trapezius muscle TENDER, Maximum mouth opening 23mm, No Mandubular Deviation to Rt./Lt., Overbite 2 mm, Overjet 3 mm, No Crossbite, Angles Class 1, Healthy spot perio probing, Soft tissue exam appears healthy, Face appears symmetrical, FMA is normal, Class 1 Skeletal,
DIAGNOSIS: The patient was informed that I feel they have myofacial pain syndrome. The cause(s) are many and can be brought on by stress, clenching, bruxing, occlusal trauma or other known and unknown factors.
TREATMENT: At this time I am prescribing a NTI to be worn at night and/or during painful events. The patient is further informed that after stablization with splint therapy that I further recommend a complete exam with the Joint Vibration Analysis and TekScan to find out if occlusal trauma is the continued source of their discomfort. Risks, benefits and alternative discussed. Next Visit: Re-eval
To construct this note I placed “Check box” variables and “Multi-choice” variables together in a logical pattern. The “Check box” variables do not have to be shown how to be construct because they are very simple to make (commas included). The “Multi-choice” variables have multiple choices and I will show what they look like in box form below. There is one “Text – single line” variable and one “Number” variable that are used to explain what kind of trauma the patient has experienced and how wide they can open their mouth.
Interestingly, according to Dr. Henry Gremillion these are the races that usually get TMD. Notice you will very rarely see an African-American with TMD.
This is the same note for all the muscle groups so just duplicate it with a different muscle in the description. I like to default to the normal and capitalize the TENDER so I can see it more clearly when scanning the note later.
FMA or Frankfort mandibular plane angle is the angle from the bottom of the orbit of the eye to the ear hole and the lower border of the mandible. If it intersects inside the base of the skull it is high. At the base of the skull is normal and out side the base of the skull is low. This helps me determine how much mesial drift the patient ma have if a tooth is extracted out of the arch. High FMA will give you rapid mesial drift and low may actually give you some distal drift. This drifting can set up interferences and relapses in the occlusion.
This note is far from complete. I’m think of adding what happens when I load the joints bilaterally.
I simply put this note up behind the patient on the computer screen and go through the outline so I don’t miss anything. Works great!
The Myofacial pain exam is not completed, yet! Next look at the T-scan/JVA notes and other blogs related to these procedures for more information.