Failure to Make the Correct Diagnosis Part III - A Surgeon's Perspective
Pushkar Mehra, Mohammed Nadershah, and Gary F. Bouloux
The complex anatomy and function of the temporomandibular joint (TMJ) and its close proximity to adjacent tissues may explain the wide spectrum of disorders involving this joint. It is often hard to identify the exact cause of TMJ pain or the factors that perpetuate the pain and dysfunction. In general, it is important to differentiate whether the symptomatology is the result of an extra-articular or intraarticular process as this can often aid in developing an appropriate differential diagnosis and treatment plan.
Making the Correct Diagnosis
A detailed pain history from the patient that addresses the onset, severity, progression, quality, radiation, and presence or absence of any aggravating and alleviating factors is crucial. A history of spontaneous or iatrogenic occlusal changes including orthodontics, orthognathic surgery, and dental prosthodontic work should be also noted. Signs
P. Mehra, BDS, DMD, FACS (*)
Department of Oral and Maxillofacial Surgery, Boston University, Henry M. Goldman School of Dental Medicine, Boston, MA, USA
M. Nadershah, BDS, MD
Oral and Maxillofacial Surgery, King Abdul Aziz University, Jeddah, Saudi Arabia G.F. Bouloux, MD, DDS, MDSc, FRACDS(OMS), FACS
© Springer International Publishing AG 2017
G.F. Bouloux (ed.), Complications of Temporomandibular Joint Surgery, DOI 10.1007/978-3-319-51241-9_3
such as joint noises, locking, and decrease in mandibular range of motion may all suggest an intra-articular disorder. Temporomandibular joint pain may be the result of internal derangement, inflammation of the synovial lining, other pathologies, or a combination of these. Involvement of multiple joints should alert the surgeon to the possibility of a systemic arthritide or condition. Altered sensation, unplanned weight loss, and hearing disturbances may be associated with a malignant TMJ process.
The clinical evaluation of the head and neck should include an examination of the muscles and TMJs and assessment for any asymmetry or skeletal deformity. An asymmetry of the facial skeleton, especially the mandible, might suggest a progressive overgrowth or resorption of one or both TMJs. Mandibular maximum interincisal opening (MIO) and excursive movements (lateral and protrusive) should accompany a thorough intraoral examination of the occlusion. Positive findings of parafunction such as signs of excessive occlusal wear facets and tongue crenations should be documented.
It is imperative that an accurate diagnosis be made prior to contemplating any nonsurgical or surgical treatment for TMJ disorders. The history and clinical examination remain the most important sources of information on which to make the correct diagnosis. Radiological imaging techniques may also be of additional help in making a correct diagnosis. In contrast to conventional imaging techniques that only provide structural information, advanced techniques like magnetic resonance scanning (MRI) and computerized tomography (CT) represent the gold standard in contemporary TMJ imaging for soft- and hard-tissue abnormalities, respectively. Additionally, nuclear imaging using radioactive isotopes offers a physiologic evaluation of the TMJ including information about active processes like inflammation, growth, or malignancy. These techniques may also allow for early detection of the condition prior to structural changes [1, 2]. Examples of this technology include single-photon emission computed tomography with technetium 99 methylene diphosphonate (SPECT/Tc-99 MDP), which gives three-dimensional images due to multiplanar imaging acquisition, and positron emission tomography (PET), which utilizes F-2-fluoro-2-deoxy-glucose, and can also be combined with CT images (PET/CT) for better anatomical correlation .