Clinical Evaluation of Orofacial Pain
Jeffrey P. Okeson and Isabel Moreno Hay
Abstract
Pain felt in the head and neck can be very
challenging for the treating clinician. There
are so many possible diagnoses, all of which
require specific treatments. Success can only
be achieved by selecting the proper treatment
for the pain condition. Therefore, differential
diagnosis is the most critical element for being
successful. Proper diagnosis can only be
achieved by acquiring the needed information
from the patient. This chapter reviews the
essential elements of taking a detailed pain
history and performing a thorough
examination.
Keywords
Orofacial pain • Temporomandibular disor-
ders • Pain history • TMD history • TMJ his-
tory • Pain examination • Clinical evaluation •
Cranial nerve • TMD evaluation • TMJ
evaluation
J.P. Okeson (*) • I. Moreno Hay
Orofacial Pain Program, College of Dentistry, University
of Kentucky, Lexington, KY, USA
e-mail: okeson@uky.edu; imo226@uky.edu
# Springer International Publishing AG 2016
C.S. Farah et al. (eds.), Contemporary Oral Medicine,
DOI 10.1007/978-3-319-28100-1_7-1
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
History of Orofacial Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The Chief Complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Past Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Review of Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Psychological Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Cranial Nerve Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Eye Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Ear Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Cervical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Muscle Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Masticatory Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Extracapsular Versus Intracapsular Restrictions . . . . . . 18
Evaluation of Oral Structures . . . . . . . . . . . . . . . . . . . . . . . . . 18
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Introduction
The ability of a clinician to establish a proper
diagnosis lays the foundation for successful treat-
ment. When the patient’s chief complaint is pain,
the most important aspect is to understand the
problem and consequently establish a proper diag-
nosis. It is critical to correctly identify the source
of the problem in order to successfully eliminate
or alleviate the pain. The diagnosis can only be
established after a thorough clinical evaluation of
the patient.
1
2 J.P. Okeson and I. Moreno Hay
In the orofacial region, diagnosis can some-
times be challenging as head and neck disorders
frequently lead to heterotopic pains that are felt in
the orofacial structures. In order to establish an
accurate diagnosis, this type of heterotopic pain,
and its source, must be identified during the his-
tory and clinical evaluation. To be effective, treat-
ment must be directed towards the source of pain
and not towards the site.
An accurate diagnosis can be established with
the information collected from the history and
clinical evaluation.
History of Orofacial Pain
The importance of taking a thorough history
cannot be overemphasized in orofacial pain dis-
orders. As much as 70–80% of the essential
information needed to make the diagnosis is
arrived at from the history. This is unlike dental
disease, where a relatively small percentage of
the information needed for diagnosis is gathered
through the history, most coming from the
examination. In orofacial pain disorders, most
of the essential information for establishing the
proper diagnosis will often come from the
history.
The process of history taking is key in making
an accurate diagnosis. In this process, the clini-
cian acquires the necessary information by ask-
ing specific questions to the patient. This process
can be performed verbally and/or by means of a
written questionnaire. The former relies on the
clinician’s ability to pursue a comprehensive set
of extensive questions, whereas a written ques-
tionnaire provides a thorough and consistent
method of history taking. Nevertheless, the latter
cannot detect nonverbal communication and
some patients have difficulty expressing their
problem using a standard form. Thus, in most
instances, the most complete method of history
taking is based on a predeveloped written ques-
tionnaire, which is then reviewed by the clinician
allowing the patient to discuss and elaborate on
any important areas.
The Chief Complaint
The starting point of history taking is to inquire
about the chief complaint, which is the reason for
the patient to seek medical care. The clinician
should ask the patient to subjectively describe
the primary symptom or concern, initially note it
in the patient’s own words and then restate it in
technical language if indicated. The medical his-
tory should always focus on the patient’s chief
complaint. However, in addition to the primary
symptom, the patient might present with other
complaints. Some complaints can be secondary
to the chief complaint, while others may be inde-
pendent. It is important to determine throughout
the clinical evaluation the relationships between
the different complaints. Understanding these
relationships is crucial for pain management.
Therefore, each of the patient’s complaints should
be enumerated and evaluated according to the
following factors
Pain Location
An evaluation of the patient’s ability to locate the
pain with accuracy provides relevant information
about the patient’s condition. The clinician should
be aware that the patient’s description of the loca-
tion of the complaint identifies only the site of
pain. The site of pain does not necessarily identify
the true source of pain. In some instances, the
structure from which the pain actually emanates
is in a different location than the site of pain. It is
the clinician’s responsibility to determine whether
it is also the true source of the pain.
A drawing of the head and neck can be very
helpful. The patient will outline the location of the
pain and can also draw arrows revealing any pat-
terns of pain referral (Fig. 1). This allows the
patient to reflect in his own way all the pain sites
and can give the clinician a significant insight
regarding the location and even the type of pain
the patient is experiencing.
Furthermore, it is also helpful to have a draw-
ing of the entire body so the clinician can take in
consideration the patient’s entire pain condition,
particularly in chronic pain conditions, such as
Clinical Evaluation of Orofacial Pain
Right Front
Fig. 1 The patient is asked to draw the location and radiation patterns of the pain on these diagrams so the clinician can
gain a better prospective of the entire pain condition
fibromyalgia (chronic widespread pain) or gener-
alized arthritic conditions.
Pain Onset
The circumstances associated with the onset of the
complaint can give great insight about the etiol-
ogy. For example, trauma such as a motor vehicle
accident can be the cause of a pain condition.
Moreover, other related injuries, such as emo-
tional trauma and even possible litigation, should
also be taken into consideration. In some cases,
systemic illnesses or even jaw function can be
related to the onset of the pain condition. How-
ever, sometimes the onset of the pain condition
can be wholly spontaneous. It is important to
gather the information regarding the
3
Left Back
circumstances associated with the onset of the
pain complaint in a chronological order to be
able to evaluate the possible cause-effect
relationship.
Pain Characteristics
The patient should specifically describe the qual-
ity, behavior, intensity, and concomitant symp-
toms of the pain complaint.
Pain Quality
Further evaluation of the pain complaint should
include descriptors of the quality of pain experi-
enced by the patient. The pain quality can be
classified as bright or dull, pricking, itching, sting-
ing, burning, aching, pulsating, or throbbing. It
4 J.P. Okeson and I. Moreno Hay
should be taken into consideration that the same
pain complaint might be described with more than
one designation.
Pain Behavior
The pain behavior should be evaluated according
to temporal behavior, duration, and localization:
I. Temporal Behavior: The frequency of pain
can be classified as intermittent, when the
pain complaint comes and goes leaving
pain-free intervals of noticeable duration that
are not related to medication intake. If such
pain-free intervals do not occur, it is classified
as continuous or persistent. When episodes
of pain, whether continuous or intermittent,
are separated by an extended period of free-
dom from discomfort only to be followed by
another similar episode of pain, the syndrome
is said to be recurrent.
II. Pain Duration: The duration of a pain episode
is an important descriptive feature that has a
significant diagnostic value. If pain duration
can be expressed in seconds, it is described as
momentary. Longer lasting pains are classi-
fied into minutes, hours, or a day. Lastly,
protracted pain continues from one day to
the next.
III. Localization: When the patient is able to
describe the exact location of the pain com-
plaint, it is described as localized pain. Con-
versely, if the location is less well defined and
vague or variable anatomically, it is termed as
diffuse pain. If the localization of pain
briskly changes, it is classified as radiating.
A more gradually change in localization of
pain is described as spreading, and if it pro-
gressively involves adjacent anatomic areas,
the pain is called enlarging. The pain com-
plaint is described as migrating if it changes
Fig. 2 The patient is asked to place a mark on a line that
has “no pain” written on one end and “the most severe pain
possible” written on the other end. The VAS score for pain
from one location to another. Referred pain is
clinical expression of heterotopic pain.
Pain Intensity
The best method to measure indirectly the inten-
sity of pain is by means of a visual analogue scale.
The patient is asked to rate the pain by placing a
mark on a line that has “no pain” written on one
end and “the most severe pain possible” written on
the other end (Fig. 2). The mark can be measured
and a pain intensity rating can be calculated. A
scale of 0–5 or 0–10 can be used to measure the
intensity of the pain, 0 being no pain and 5 or
10 being the most pain possible. This is a useful
instrument for quantification of pain. Although it
is not appropriate tool to compare different
patients since pain is a subjective experience and
varies greatly from patient to patient, this scale
can be helpful when comparing initial pain with
pain at follow-up appointments to assess the treat-
ment efficacy.
Concomitant Symptoms
Any sensory, motor, or autonomic symptoms that
accompany the pain should be included in the
history. Concomitant sensory symptoms such as
hyperesthesia, hypoesthesia, anesthesia, paresthe-
sia, or dysesthesia should be mentioned. Addi-
tionally, changes in the special senses affecting
vision, hearing, smell, or taste can also be present.
Regarding motor changes, symptoms such as
muscular weakness, muscular contractions, or
actual spasm should be recognized. Concomitant
autonomic symptoms may include ocular symp-
toms such as lacrimation, injection of the conjunc-
tive, pupillary changes, and edema of the lids;
nasal symptoms include nasal secretion and con-
gestion; cutaneous symptoms have to do with skin
temperature, color, sweating, and piloerection
gastric symptoms include nausea and indigestion.
intensity is measured from the left. In this figure, the pain
intensity is quantified as 4/10
Clinical Evaluation of Orofacial Pain
Any of these concomitant symptoms should be
documented and the relationship to the pain com-
plaint analyzed.
Flow of Pain
The manner of flow is determined by whether the
episodes of pain are steady or paroxysmal. A
steady pain is a flowing type of pain that can be
variable in intensity or even intermittent. On the
other hand, sudden volleys or jabs that may vary
in intensity and duration characterize paroxysmal
pain. When the volleys occur frequently, the pain
may become nearly continuous.
Aggravating and Alleviating Factors
Effect of Functional Activities
The effect of functional activities should be
observed and described. Activities such as shav-
ing or washing the face may trigger the pain by
minor superficial stimulation, touch or move-
ment of the skin, lips, face, tongue, or throat.
Furthermore, pain can also be induced as the
result of functioning of the joints and muscles
themselves in functional activities such as
talking, chewing, yawning, turning the head,
etc. In order to distinguish between the effects
of both functional activities, it can be very help-
ful to stabilize of joints and muscles, and ulti-
mately using topical anesthesia. The effect of
emotional stress, fatigue, and time of day should
also be recorded.
Similarly, parafunctional activities should also
be investigated. Any intraoral or extraoral force
applied to the jaw should be noted as a potential
contributing factor to functional disturbance
(Chun and Koskinen-Moffett 1990). The patient
should be questioned regarding parafunctional
habits such as bruxism or any other oral habit.
However, the clinician should be aware that
often these activities occur at subconscious levels
and the patient may not accurately reporting them,
particularly with bruxing and clenching. Other
parafunctional habits can include holding objects
between the teeth like a pipe, pencils, or occupa-
tional implements. Moreover, extraoral forces can
be applied by holding a telephone between the
chin and shoulder, resting the mandible in the
5
hands while sitting at a table or playing certain
musical instruments (Howard 1991).
Emotional Stress
Emotional stress can play a significant role in the
pain complaint. When this is the case, patients will
report that the pain seems to be accentuated during
times of increased stress. It is important for both
the clinician and the patient to recognize this
relationship, as the diagnosis and treatment plan
will depend on it. The patient should be
questioned for any correlation between symptoms
and high levels of emotional stress, and the peri-
odicity of symptoms. The role that emotional
stress plays in the patient’s chief complaint can
only be identified with a thorough history. The
presence of other psychophysiological disorders
(e.g., irritable bowel syndrome (IBS), hyperten-
sion, colitis) helps document the effect of stress on
the patient.
Sleep Quality
The quality of the patient’s sleep should also be
reviewed because there is a relationship between
some pain conditions and the quality of the sleep
(Moldofsky et al. 1975; Moldofsky and
Scarisbrick 1976; Molony et al. 1986; Saletu
et al. 2005). Patients should be asked about sleep
latency, awakenings throughout the night and
daytime tiredness. It is also important to assess if
the pain condition actually awakes them from
sleep.
Disability and Litigation
It is relevant to the diagnosis and treatment plan to
recognize if the patient is involved in any form of
litigation related to the pain complaint, as well as
receiving or applying for disability that will allow
the patient to receive compensation. In some
instances, secondary gain could be present and
indirectly related to the chief complaint.
Past Consultations and Treatments
All the previous patient’s consultations and treat-
ments should be thoroughly discussed and
reviewed during the interview, so unnecessary
test or therapies are repeated. If the information
provided the patient is incomplete or unclear, it is
6 J.P. Okeson and I. Moreno Hay
recommended to contact the previous treating cli-
nician to gather the appropriate information.
All past and present medications taken for the
pain condition should be reviewed. The patient
should be asked to report dosages along with the
frequency taken, prescribing doctor and effective-
ness in altering the chief complaint.
Additionally, the effect of different physical
modalities on the pain condition, including appli-
cation of hot and cold, massage, transcutaneous
electrical nerve therapy should be investigated.
The response to such therapies may shed light on
the appropriate type and therapeutic intervention.
The patient should be asked to bring any occlu-
sal appliance received to the evaluation appoint-
ment. This evaluation may shed light on future
treatment considerations.
Past Medical History
The history should include a complete past med-
ical history to identify any major medical problem
that can play an important role in functional dis-
turbances. Any past serious illnesses, hospitaliza-
tions, operations, medications, or other significant
treatments should be noted. Even if the symptoms
of the chief complaint are not related to a major
medical problem, the existence of such a medical
problem may play an important role in selecting
the treatment plan. When indicated, treating phy-
sicians should be contacted for additional infor-
mation. It may also be appropriated to discuss
your suggested treatment with the patient’s phy-
sician when significant health problems are
present.
Review of Systems
A complete history should also include appropri-
ate questions concerning the presence of subjec-
tive symptoms covering the organ systems:
cardiovascular, hematologic, neurologic, diges-
tive, respiratory, genitourinary, skin, musculo-
skeletal, and endocrine. Any abnormalities
should be noted and any relationship with the
pain complaint should be determined.
Psychological Evaluation
In acute pain conditions, a routine psychological
evaluation may not be necessary, in chronic pain
conditions however, psychological factors
become more relevant and a psychological evalu-
ation becomes essential. For this reason, chronic
pain patients are best evaluated and managed by a
multidisciplinary team.
To assess the patient’s psychological status,
there are a wide variety of psychological measur-
ing tools that can be used. Turk and Rudy (1987)
developed the Multidimensional Pain Inventory
(MPI) to evaluate the chronic pain experience,
classifying the patient into three pain profiles:
adaptive coping, interpersonal distress and dys-
functional chronic pain. The dysfunctional
chronic pain profile of severe pain is accompanied
by functional disability, psychological impair-
ment and low perceived life control.
The Symptom Check List 90 (SCL-90) is
another useful instrument (Derogatis 1977) that
helps evaluate the following eight psychological
states: somatization, obsessive-compulsive
behavior, interpersonal sensitivity, depression,
anxiety, hostility, phobic anxiety, paranoid idea-
tion, and psychoticism.
Psychologic assessment is also important not
only to identify mood and anxiety disorders, but
also other type of mental disorders such as
somatic symptom and related disorders.
According to the DSM-5 (Association TAP
1994), these disorders are characterized by phys-
ical complaints associated with significant levels
of distress and impairment that may not have an
evident medical explanation. One of the most
common reported somatic symptoms is pain.
These conditions include somatic symptom disor-
der, functional neurological symptom disorder
(also called conversion disorder), illness anxiety
disorder (hypochondriasis), among others. An
evaluation of these conditions should be made
by a trained psychologist or psychiatrist.
Often the general practitioner may not have
immediate access to psychological evaluation
support. In this instance, the practitioner may
elect to use the IMPATH (Fricton et al. 1987) or
the TMJ Scale (Levitt et al. 1988). The new
Clinical Evaluation of Orofacial Pain
DC/TMD (diagnostic criteria for temporomandib-
ular disorders) (Schiffman et al. 2014) recom-
mend the use of the following screening tools:
the Patient Health Questionnnaire-4 (PHQ-4) to
detect anxiety and depression, the Graded
Chronic Pain Scale (GCPS) to assess pain inten-
sity and pain-related disability; the short form of
the Jaw Functional Limitation Scale (JFLS) and
the Oral Behavioral Checklist (OBC) to evaluate
parafunctional habits. These scales have been
developed for use in the private dental practice
to assist in evaluating clinical and certain psycho-
logical factors associated with orofacial pains.
These scales can assist the clinician in identifying
whether psychological issues are an important
aspect of the patient’s pain condition. Although
these scales are helpful, they are not as complete
as the above psychological tests and certainly do
not replace personal evaluation by a clinical
psychologist.
Clinical Evaluation
Once the history has been obtained, the clinical
evaluation is performed. The purpose of the clin-
ical examination is to identify any variations from
normal health and function of the orofacial
structures.
As part of the clinical evaluation of the
orofacial pain, it is important to evaluate the
gross function of the cranial nerves and the eyes,
ears, and neck. If any abnormal findings are iden-
tified, an immediate referral to the appropriate
specialty is indicated (Drum et al. 1993) .
Vital Signs
Blood pressure, pulse rate, respiration rate, and
body temperature should be taken as part of the
general examination.
Cranial Nerve Examination
In orofacial pain conditions, the gross function of
the 12 cranial nerves should be tested to rule out
7
neurologic disorders. The cranial nerve examina-
tion does not need to be complex. If any gross
problem relating to their function is identified, it
should be immediately and appropriately
addressed. The following evaluation procedures
can assess each cranial nerve.
Olfactory Nerve (I)
The first cranial nerve has sensory fibers originat-
ing in the mucous membrane of the nasal cavity
and provides the sensation of smell. To test the
function of the olfactory nerve, the patient is asked
to distinguish between intense odors (i.e., vanilla,
peppermint or chocolate). The mirror test can be
used prior to assess nasal patency. The fogging
pattern on the surface of the mirror reflects the
nasal airflow.
Optic Nerve (II)
The second cranial nerve is also sensory with
fibers originating in the retina providing sight.
Asking the patient to cover one eye and read a
few sentences can assess the patient’s visual acu-
ity. Each eye should be evaluated independently.
Secondly, the visual field is evaluated by standing
behind the patient and slowly bringing the fingers
towards the nose while the patient is looking
forward. Patient should report when the clini-
cian’s fingers are first noted. No discrepancies
should exist between the right and left side.
(Fig. 3)
Fig. 3 Visual field (optic nerve) test: with the patient
looking forward, the examiner’s fingers are brought around
to the front from behind. The initial position at which the
fingers are seen marks the extent of the visual field. Right
and left fields should be very similar
8 J.P. Okeson and I. Moreno Hay

Oculomotor, Trochlear, and Abducent

Nerves (III, IV, VI)
The third, fourth, and sixth cranial nerves supply
motor fibers to the extraocular muscles. To test the
three of them, the patient is asked to follow, with
the eyes and not the head, the finger as the clini-
cian draws an “S” or “X.” The eyes should move
smoothly and similarly as they follow the clini-
cian’s finger. Both pupils should be equal in size,
round and reactive to light. To test the accommo-
dation reflex, the patient is asked to change focus
from a distant to a nearby object. In order to focus
in when the object approaches the patient’s face,
the pupils should constrict. The reactivity to light
is tested with direct light stimulus to the pupil. The Fig. 4 Pupil constriction test under direct light stimulus:
pupil not only constricts to direct light but also the opposite pupil should also constrict, demonstrating the
constricts to light directed in the other eye (con- consensual light reflex
sensual light reflex) (Fig. 4).

Trigeminal Nerve (V)

The fifth cranial nerve has two components: the
sensory component responsible for the sensation
from the face, scalp, nose, and mouth and the
motor component that supplies the muscles of
mastication. Facial sensation can be tested by
lightly stroking the face with a cotton tip bilater-
ally over the three sensory regions innervated by
the ophthalmic, maxillary, and mandibular
branches of the trigeminal nerve: forehead,
cheek, and lower jaw, respectively (Fig. 5). The
patient should describe similar sensations on each
side. The trigeminal nerve also contains sensory Fig. 5 Trigeminal nerve sensory function test: cotton tip
fibers from the cornea that can be tested simulta- applicators are used to compare light touch discrimination
neously with the corneal reflex. Light touch to the between the right and left maxillary branches of the tri-
geminal nerve. The ophthalmic and mandibular branches
cornea innervated by the afferent fibers of the are also tested
trigeminal nerve with sterile cotton should elicit
a blink response innervated by efferent motor evaluated by asking the patient to distinguish
fibers of the VII nerve. between sweet and salt using just the tip of the
The gross motor input can be assessed by pal- tongue. The patient is asked to raise both eye-
pation of both masseter and temporal muscles brows, smile, and show the lower teeth to evaluate
when the patient clenches the teeth. The contrac- the motor component, responsible for the muscles
tion of the muscle should be felt equally on both of facial expression. Any bilateral differences are
sides. (Fig. 6) recorded during these movements.

Facial Nerve (VII) Acoustic Nerve (VIII)

The seventh cranial nerve is sensory and motor. The eighth cranial nerve supplies the senses of
The sensory component, supplying taste sensa- balance and hearing, also called vestibulo-
tions from the anterior portion of the tongue, is cochlear nerve. Patients should be asked if they
Clinical Evaluation of Orofacial Pain 9

Fig. 7 Gross hearing test: rubbing a strand of hair between

the finger and thumb near the patient’s ear to identify any
difference between right and left hearing sensitivities
Fig. 6 Trigeminal nerve motor function test: the patient is
asked to clench the teeth together while the clinician feels
for equal contraction of the right and left masseter muscles.
This is also done for the temporalis muscles

have experienced any problems with balance or

coordination. To test balance and coordination,
the patient is asked to walk heel-to-toe along a
straight line. Hearing impairment can be evalu-
ated by the clinician rubbing their first finger and
thumb near the patient’s ear noting any difference
between right and left sensitivities. (Fig. 7)

Glossopharyngeal and Vagus Nerves

(IX, X)
Both cranial nerves supply fibers to the back of the
throat. To test both nerves, symmetric elevation of
the soft palate should be observed when the
patient pronounces vocal “a.” Similarly, by touch-
ing the pharyngeal walls a gag reflex is induced.
This gag reflex involves the afferent innervation
of the glossopharyngeal nerve and the efferent
motor innervation of the glossopharyngeal and
vagus nerve.
Accessory Nerve (XI)
The spinal accessory nerve supplies fibers to the
sternocleidomastoid and trapezius and muscles.
To test the motor innervation of the sternoclei-
domastoid muscle, the patient is asked to tilt the
head laterally against resistance. For the motor
innervation of the trapezius, the patient shrugs
Fig. 8 Spinal accessory motor function test: the patient
moves the head first to the right and then to the left against
resistance. The right and left sides should be relatively
equal in strength
the shoulders against resistance. Any differences
in muscle strength should be noted (Fig. 8).
Hypoglossal Nerve (XII)
The twelfth cranial nerve innervates the muscles
of the tongue. To test it, the patient is asked to
protrude the tongue and move it side-to-side as
well as pushing laterally against a tongue blade.
Any deviations from the midline should be noted
as well as differences in relative strength of both
sides.
10
Autonomic Function
The parasympathetic innervation of the oculo-
motor or third cranial nerve is assessed simulta-
neously while testing the pupillary light reflex.
The facial or seventh and glossopharyngeal or
ninth nerves’ parasympathetic function can be
evaluated by testing lacrimation and salivation.
The presence of Horner’s syndrome character-
ized by miosis, ptosis and facial anhidrosis,
indicates and deficit in cranial sympathetic
activity.
If any abnormalities are noted during the cra-
nial nerve evaluation, referral to a neurologist
should be made.
Eye Examination
In addition to the cranial nerve examination, any
changes in vision, diplopia, or blurriness of vision
should be documented as well as whether this
relates to the pain problem. Pain felt in or around
the eyes should be noted and whether or not
reading affects it. Reddening of the conjunctivae
should be recorded along with any tearing or
swelling of the eyelids.
Ear Examination
Ear pain is a common source of orofacial pain and
needs to be ruled out as the origin of the patient’s
chief complaint. Moreover, due to the proximity
of the TMJ, it is not uncommon that patients
report ear pain as an associated symptom. There-
fore, an ear examination is recommended as part
of the clinical examination of an orofacial pain
condition. An otoscopic examination can be
performed by gentling pulling the auricle and
inspecting the external auditory canal and tym-
panic membrane. Tenderness upon pulling the
auricle could be a clinical sign of otitis media. If
any other abnormalities are noted such a swelling,
infection, erythema, or hemorrhage, referral to an
otorhinolaryngologist should be arranged for a
more thorough evaluation. On the other hand,
normal findings from an otologic examination
J.P. Okeson and I. Moreno Hay
Fig. 9 Ear evaluation: an otoscope is used to visualize the
external ear canal and the tympanic membrane for any
unusual findings. If abnormal findings are suspected the
patient should be referred to an otolaryngologist for a
thorough evaluation
may be taken as encouragement to continue to
search for the true source of pain (Fig. 9).
Cervical Evaluation
It is important to evaluate the presence of any
cervical spine disorder that might be related to
the patient’s chief complaint. Pain arising from
the cervical structures can refer pain to the
orofacial structures. A simple screening examina-
tion can be accomplished by examining the cervi-
cal range of motion and the presence of pain
during movement. With the patient seated in an
upright position, neck flexion, extension, rotation,
and lateral tilt are measured. There should be at
least 70! of rotation in each direction (Okeson
2013a). The head should normally extend back-
ward some 60! and flex downward 45! . This
should be possible to approximately 40! each
way. The presence of any pain during the tests or
any limitation of movement should be noted
(Fig. 10a–d).
If the clinician suspects that the patient has a
cervical spine disorder, referral for a more com-
plete (cervicospinal) evaluation is indicated. This
is important, since craniocervical disorders can be
closely associated with orofacial pain disorders
Clinical Evaluation of Orofacial Pain
Fig. 10 Cervical range of movement: (a) the patient is
asked to look to the extreme right and the extreme left, (b)
look upward fully, (c) look downward fully, and (d) bend
(Clark 1987; Visscher et al. 2009; Fernandez-de-
Las-Penas et al. 2009).
Muscle Evaluation
The muscle evaluation includes muscle palpation
to determine the presence of pain or tenderness
and muscular functional manipulation.
Muscle Palpation
Digital palpation is a widely accepted method of
determining the presence of muscle tenderness
and pain (Burch 1977; Okeson 2013a). Digital
palpation produces a tissue deformation that in
compromised muscle tissue can elicit pain (Frost
1977). A healthy muscle tissue does not elicit
pain; thus, when pain is reported upon palpation,
it can be deduced that the muscle tissue has been
11
the neck to the right and left. Any restriction of movement
is noted and considered in the pain diagnosis
compromised by either trauma or fatigue. An
objective quantitative assessment of pain or ten-
derness upon pressure can be obtained by using a
pressure algometer (Fig. 11).
Palpation of the muscle is accomplished
mainly by applying soft but firm pressure with
the palmar surface of the middle finger and with
the index finger or forefinger testing the adjacent
areas in a small circular motion.
Any pain or discomfort elicited during muscle
examination should be noted to later be used in the
evaluation and assessment of progress.
Clinical Significance of Trigger Points
While performing a thorough muscle examina-
tion, the clinician should identify the presence of
localized, taut, hypersensitive bands of muscle
tissue (trigger points), and indicative of
myofascial pain. When a trigger point is located,
12
Fig. 11 Pressure algometer can be used to obtain an
objective quantitative assessment of pain or tenderness
upon palpation
the clinician should maintain the pressure over the
taut band to determine if a pattern of pain referral
is elicited. Pressure should be applied for 4–5 s
and the patient is asked if the pain is felt to radiate
in any direction. The patterns of referred (hetero-
topic) pain should be documented on a drawing of
the face for future reference in identifying and
diagnosing the pain conditions.
Travell and Simons outlined the specific pat-
tern of referred pain from various trigger point
locations (Travell and Simons 1983; Simons
et al. 1999), but further studies are still needed to
establish reliable diagnostic criteria for myofascial
trigger points. An understanding of these common
referral sites may help the clinician who is
attempting to diagnose a facial pain problem. For
example, when a patient’s chief complaint is head-
ache, careful palpation of the aforementioned
neck muscles for trigger points will demonstrate
its source (Travell and Rinzler 1952).
When the source of pain is difficult to identify,
a diagnostic anesthetic injection delivered to the
trigger point can be very helpful to confirm the
diagnosis. Local anesthetic blocking often not
only provides diagnostic information, but it can
also have therapeutic value (Okeson 2013b).
Once the trigger point has been located, the
tissue should be cleaned with alcohol, and the
taut band trapped between two fingers. When the
needle is inserted in the area, aspiration with the
syringe should be performed to avoid injection of
J.P. Okeson and I. Moreno Hay
local anesthetic into a vessel. Once the injection
has been completed, it is recommended to apply
slight pressure at the site with a sterile gauze for
10 to 15 s. The clinician must be familiar with the
local anatomy to avoid other structures in the
vicinity. A few minutes after the infiltration,
patient should be asked to report pain relief not
only at the site of the injection but also the referred
location. In some cases, the benefit of the injection
can last longer than the effect of the local
anesthetic.
A routine muscle examination should include
the palpation of the following muscles:
temporalis, masseter, sternocleidomastoid, and
posterior cervical (e.g., the splenius capitis and
trapezius). Simultaneous bilateral pressure is
recommended except for the sternocleidomastoid.
To perform a proper muscle evaluation, it is cru-
cial to have a thorough understanding of the anat-
omy and function of the muscles.
Temporalis Muscle
The temporalis muscle is a fan-shaped muscle that
can be divided into three functional areas, and
each area is independently palpated. The muscle
fibers of the anterior region run in a vertical
direction and can be palpated above the zygomatic
arch and anterior to the TMJ. The fibers in the
middle region run in an oblique direction across
the parietal area and are palpated directly above
the TMJ and superior to the zygomatic arch. The
fibers in the posterior region run horizontally and
can be palpated above and behind the ear
(Fig. 12a–c).
To determine the proper position of the fingers,
the patient is asked to clench the teeth together.
The temporalis will contract and the fibers should
be felt beneath the fingertips. It is helpful to be
positioned behind the patient and to palpate the
muscle areas bilaterally and simultaneously.
It is important also to palpate the tendon of the
temporalis muscle. The fibers of the temporalis
muscle converge into a tendon that runs medially
to the zygomatic arch and inserts onto the
coronoid process of the mandible. Temporalis
tendonitis can generate pain in the body of the
muscle as well as referred pain behind the adja-
cent eye (retro-orbital pain). The tendon of the
Clinical Evaluation of Orofacial Pain
Fig. 12 Palpation of the temporal muscles: (a) the anterior region, (b) the middle region, and (c) the posterior region
temporalis is palpated by placing the finger
intraorally on the anterior border of the ramus
and moved up until the coronoid process and the
insertion of tendon are palpated. The patient is
asked to report any discomfort or pain.
Masseter Muscle
The masseter muscle is palpated bilaterally at its
superior and inferior attachments. The fingers
should be placed slightly inferior to the zygomatic
arch, just anterior to the TMJ. Then the fingers drop
along the muscle fibers to the inferior attachment on
the inferior border of the ramus (Fig. 13a, b).
Sternocleidomastoid Muscle
The palpation of the sternocleidomastoid (SCM)
is done bilaterally near its insertion on the outer
surface of the mastoid fossa, behind the ear. The
entire length of the muscle is palpated, down to its
origin near the clavicle. The patient is asked to
report any discomfort during the procedure. The
13
sternocleidomastoid muscle is a frequent source
of referred pain to the temporal, joint, and ear area
(Fig. 14a, b).
Posterior Cervical Muscles
The posterior cervical muscles are the major
group responsible for cervical function. This
group of muscles includes trapezius, longissimus
(capitis and cervicis), splenius (capitis and
cervicis), and levator scapulae. They originate at
the posterior occipital area and extend inferiorly
along the cervical spine region.
To palpate this group of muscles, the examiner
places the fingers behind the patient’s head at the
origin of the muscles. The fingers move down the
length of the neck muscles through the cervical
area. It is important to be aware of referral pain
from these muscles since they are a common
source of frontal headache. The patient is
questioned regarding any discomfort during pal-
pation (Fig. 15a, b).
14
Fig. 13 Palpation of the masseter muscles: (a) the superior attachment to the zygomatic arch and (b) the superficial
masseter muscle near the lower border of the mandible
Fig. 14 Palpation of the sternocleidomastoid muscles: (a) superior near the mastoid process and (b) inferior near the
clavicle
The splenius capitis is palpated at its attach-
ment to the skull at a small depression just poste-
rior to the attachment of the SCM. Any pain,
tenderness, or trigger points noted during palpa-
tion are recorded.
The trapezius is an extremely large muscle of
the back, shoulder, and neck that can be easily
palpated and is a common source of referred pain
and headache. The upper part is palpated from
behind the SCM, inferolaterally to the shoulder,
and any trigger points are recorded (Fig. 16).
Functional Manipulation
As previously mentioned, the muscle examination
also includes the muscular functional manipula-
tion. During functional manipulation, each mus-
cle is contracted and then stretched. If the muscle
J.P. Okeson and I. Moreno Hay
is a true source of pain, both activities will
increase the pain. This technique is used for mus-
cles that are impossible or nearly impossible to
palpate manually. There are three muscles that are
basic to jaw movement but impossible or nearly
impossible to palpate: the inferior lateral ptery-
goid, superior lateral pterygoid, and medial pter-
ygoid muscles. All three muscles receive their
innervation from the mandibular branch of the
trigeminal (V) nerve.
The lateral pterygoid originates on the lateral
wing of the sphenoid bone and the maxillary
tuberosity and inserts on the neck of the mandib-
ular condyle and the TMJ capsule. The medial
pterygoid has a similar origin, but it extends
downward and laterally, to insert on the medial
surface of the angle of the mandible. Although the
Clinical Evaluation of Orofacial Pain
Fig. 15 (a) palpation of muscular attachments in the occipital region of the cervical spine. (b) the fingers are brought
inferiorly down the cervical area and the muscles are palpated for pain and tenderness
Fig. 16 The trapezius is palpated as it ascends into the
shoulder structures
medial pterygoid can be directly palpated by plac-
ing the finger in the lateral aspect of the pharyn-
geal wall of the throat, this palpation is difficult
and sometimes uncomfortable for the patient (gag
reflex).
If pain is increased during resisted protrusion
of the mandible, the inferior lateral pterygoid
should be suspected as a source of pain. If pain
increases during power stroke (clenching) in max-
imum intercuspation, the inferior or the superior
lateral pterygoid might be the source of pain.
Finally, to test the medial pterygoid as the source
of pain, it will increase when the mouth is opened,
when clenching the teeth and clenching on a sep-
arator. A more detailed description can be found
in other texts (Okeson 2013b).
15
Masticatory Evaluation
The masticatory structures can be a common
source of orofacial pain. To identify any pain or
dysfunction, a thorough examination should be
performed. The clinician should evaluate the
range of movement, the TMJs, as well as the
oral structures.
Mandibular Range of Motion
The range of movement during mouth opening is
the distance that the jaw travels between maxi-
mum intercuspation and mouth opening. The
range of motion is calculated by measuring the
distance in millimeters (mm) between the incisal
edges of the maxillary and mandibular anterior
incisors, adding the amount of positive frontal
overlap in patients with overbite, or subtracting
the negative frontal overlap in cases of anterior
open bite. An initial measurement of maximum
comfortable opening is obtained by asking the
patient to open slowly until the pain is first
noted. The maximum mouth opening is then
recorded by asking the patient to open as wide as
possible despite the pain. In the absence of pain,
no restrictions are expected; thus, the maximum
comfortable opening and the maximum mouth
opening are identical (Fig. 17a, b).
The normal range of mouth opening is 53 to
58 mm (Agerberg and Osterberg 1974) measured
between the incisal edges of the maxillary and
mandibular teeth. A patient can normally open a
16 J.P. Okeson and I. Moreno Hay

Fig. 17 Mouth opening evaluation: (a) The patient is maximum comfortable mouth opening. (b) The patient is
asked to open the mouth until pain is first felt. At this than asked to open as wide as possible even in the presence
point the distance between the incisal edges of the anterior of pain. This measurement is called the maximum mouth
teeth is measured. This measurement is called the opening

maximum 40 mm or more, even at the age of

6-year-old (Solberg 1976; Vanderas 1992).
Among young adults only 1.2% open less than
40 mm and among healthy elderly population
15% (Bitlar 1991); therefore, less than 40 mm is
consider as a reasonable point to determine
restriction upon mouth opening. Nevertheless,
the patient’s age and body size should always be
taken into consideration.
When restriction in mouth opening is noted, it
is helpful to test the “end feel.” The end feel
describes the characteristics of the restriction
that limits the full range of joint movement
Fig. 18 Checking the “end feel”. Gentle but steady pressure
(McCarroll et al. 1987). The end feel can be is placed on the lower incisors for approximately 10–15 s.
evaluated by placing the fingers between the Increased mandibular opening indicates a soft end feel (usu-
patient’s upper and lower teeth and applying gen- ally associated with a masticatory muscle disorder)
tle but steady force in an attempt to passively
increase the interincisal distance. If the end feel Not only is the distance during mandibular
is “soft,” increased opening can be achieved but it movements evaluated but also the path taken by
must be done slowly. A soft end feel suggests the midline of the mandible. In the healthy masti-
muscle-induced restriction (Hesse et al. 1990). If catory system, a straight opening and protruding
no increase in opening can be achieved, the end pathway should be observed. During mouth open-
feel is said to be “hard.” Hard end feels are more ing, two types of abnormalities can occur: devia-
likely associated with intracapsular sources (e.g., tions and deflections. A deviation is considered as
a disc dislocation) (Fig. 18). any shift of the jaw midline during opening that
The range of movement of excursive move- disappears with continued opening (a return to
ments of the mandible is also evaluated. The midline). It is a result of the incoordination of
patient is instructed to move his mandible later- the movement of both condyles, usually due to a
ally and to protrude. Any excursive movements disc derangement in one or both joints. The
less than 8 mm are considered a restricted straight midline path is resumed once the condyle
movement. has overcome this interference. A deflection is
Clinical Evaluation of Orofacial Pain
any shift of the midline to one side that becomes
greater with opening and does not disappear at
maximum opening (does not return to midline).
It is due to restricted movement in one joint. The
source of the restriction varies and must be
investigated.
Temporomandibular Joint Examination
Any signs or symptoms associated with pain and
dysfunction of the temporomandibular joints are
evaluated.
Temporomandibular Joint Pain
Any pain or tenderness arising from the TMJs is
examined by digital palpation of the joints during
postural position and dynamic movements of the
mandible. To locate the lateral aspect of the TMJ,
the patient is asked to open and close a few times;
in this way the clinician can feel the lateral poles of
the condyles passing downward and forward
across the articular eminences. Once the fingertips
are placed over the lateral aspect, both TMJs are
palpated simultaneously by applying pressure to
the joint area. Once the symptoms are recorded in a
closed mouth position, the patient is asked to open
maximally, and the posterior aspect of the TMJ is
then palpated by rotating the fingertips slightly
posterior. Posterior capsulitis and retrodiscitis are
clinically evaluated in this manner. The symptoms
associated with the opening and closing mouth
movement should be recorded (Fig. 19a, b).
Fig. 19 Palpation of the TMJ: (a) the lateral aspect of the
joint is palpated with the mouth closed. (b) The patient is
then asked to open and close the mouth noting any pain or
17
The clinician must have a sound understanding
of the anatomy of the region, to evaluate the
temporomandibular joint effectively. When the
patient is asked to clench and the clinician’s fin-
gers are placed properly over the lateral poles of
the condyles very little to no movement is felt.
However, if the fingers are misplaced only 1 cm
anterior to the lateral pole and the deep portion of
the masseter can be felt contracting. In this ana-
tomic region, a portion of the parotid gland
extends to the region of the joint, the clinician
should be aware that parotid gland related symp-
toms can also arise from this area. A correct dif-
ferential diagnosis should be established to
identify whether the symptoms are originating
from the joint, muscle, or gland. The basis of
treatment will be determined by this evaluation.
Temporomandibular Joint Dysfunction
Temporomandibular joint dysfunction can be sep-
arated into two types: joint sounds and joint
restrictions.
Joint Sounds
Joint sounds can be generally classified as either
clicks or crepitation. A click is defined as a single
sound of short duration. If it is relatively loud, it
can be referred to as a pop. On the other hand,
crepitation or crepitus is a multiple crackling,
grating, or rattling sound. Crepitation is most
commonly associated with osteoarthritic changes
joint sounds. When the mouth is fully opened, the finger
can be moved behind the condyle to palpate the posterior
aspect of the joint
18
of the articular surfaces of the joint (Bezuur et al.
1988).
Joint sounds can be assessed by placing the
fingertips over the lateral surfaces of the joint
during mouth opening and closing movements
or by using a stethoscope or a joint sound record-
ing device. When these more sensitive devices are
used the clinician must appreciate that many more
sounds will be detected than mere palpation,
which might not have any clinical significance.
In fact, it might lead the clinician to unnecessary
treatment. Therefore, in most instances, palpation
techniques are more than adequate to assess TMJ
sounds.
It is not recommended to examine the TMJ
sounds by placing the fingers inside the patient’s
ears. This technique can actually produce joint
sounds that are not present during normal function
of the joint (Hardison and Okeson 1990) by forc-
ing the ear canal cartilage against the posterior
aspect of the joint producing additional sounds.
The range of mandibular movement associated
with the sound should also be recorded. The
interincisal distance associated with the sound
will be noted during opening and closing
movements.
The presence or absence of joint sounds is
associated with the disc position and provides
information regarding the TMJ dynamics. How-
ever, the absence of sounds does not always
mean normal disc position. In one study 15%
of silent, asymptomatic joints were found to
have disc displacements on arthrograms
(Westesson et al. 1989; Westesson et al. 1990).
Thus, all the clinical findings should be taken in
consideration to evaluate the clinical signifi-
cance of joint sounds.
Joint Restrictions
Any irregularities or restrictions during mandibu-
lar movements should be noted. Restricted move-
ments of the mandible are caused by either
extracapsular or intracapsular sources. The former
are generally the muscles and therefore relate to a
muscle disorder. The latter are generally associ-
ated with the TMJ disc-condyle function and the
surrounding ligaments and thus are usually related
to a disc derangement disorder. Extracapsular and
J.P. Okeson and I. Moreno Hay
intracapsular restrictions present with different
characteristics.
Extracapsular Versus Intracapsular
Restrictions
In order to establish a differential diagnosis
between extracapsular and intracapsular restric-
tions, the following characteristics should be
taken into consideration.
The main characteristic of extracapsular
restrictions is that normal eccentric movements
are present whereas opening movement is
restricted. Usually, the sources of the extra-
capsular restrictions are typically elevator muscle
spasms and pain. These muscles tend to restrict
translation and thus limit opening. The restriction
can range anywhere from 0 to 40 mm
interincisally. With this type of restriction, the
patient is usually able to increase opening slowly,
but the pain is intensified (soft end feel).
A deflection of the incisal path during open-
ing can be observed with extracapsular restric-
tions. The direction of the deflection depends on
the location of the muscle that causes the restric-
tion. If the restricting muscle is lateral to
the joint (as with the masseter), the deflection
during opening will be to the ipsilateral side.
If the muscle is medial (as with the medial
pterygoid), the deflection will be to the
contralateral side.
On the other hand, intracapsular restrictions
can be easily differentiated from the extra-
capsular restrictions. An intracapsular restriction
limits the translation of the TMJ but does not
interfere with the rotation of the condyle. As a
result, the patient is able to open between 25 to
30 mm, which also depends if one or both TMJs
are involved. A deflection of the incisal path
during opening to the ipsilateral (affected) side
will be observed.
Evaluation of Oral Structures
The oral structures including teeth and supportive
structures must be carefully examined.
Clinical Evaluation of Orofacial Pain
Mucogingival Tissues
The gingiva and entire oral mucosa should be
tested by touch, pinprick, and manual palpation
to identify areas of abnormal sensibility. Visual
inspection of the superficial mucogingival tissues
of the mouth and throat is done to identify hyper-
emia, inflammation, abrasion, ulceration, neo-
plasm, or other abnormality.
Dental Tissues
There is no doubt that pains in the mouth and face
stem most frequently from local dental causes,
and a thorough examination of the teeth is an
indispensable part of the orofacial examination.
Odontogenic pains have the propensity to simu-
late many other pain disorders, and hence, careful
examination is needed to arrive at a diagnosis.
Periodontum
The periodontal condition, especially in the region
of the pain, should be carefully evaluated. Gingi-
val tissue color and surface texture should be
noted. A periodontal probe should be used to
identify any loss of gingival attachment or
pocketing that might be associated with the pain.
The tooth should be percussed apically and later-
ally to determine any relationship to the pain.
Radiographs should be taken to help identify any
changes in the alveolar bone support of the teeth
(e.g., widening of the periodontal space,
osteosclerosis, hypercementosis).
Whenever tooth mobility is present, it can
result from either loss of bony support, such as
periodontal disease, or by unusual traumatic
occlusal forces. Both factors should be taken
into consideration.
Occlusion
To examine a patient’s occlusal condition, it is
necessary to have an appreciation of what is con-
sidered normal and what is considered function-
ally optimal, as these two conditions are not
identical. The clinician must be aware that the
occlusal condition is rarely a factor in the distur-
bance and by merely examining an occlusal con-
dition, cannot determine the relationship with the
orofacial pain disorder. Although some studies
have suggested a relationship between different
19
malocclusions and the symptoms of TMD
(Kirveskari et al. 1992; Tanne et al. 1993;
Egermark-Eriksson et al. 1987), others do not
seem to corroborate this statement (Gremillion
2006; DeBoever and Adriaens 1983; McNamara
et al. 1995; Wadhwa et al. 1993; Manfredini et al.
2014). To this date, the controversy still remains
and the relationship of dental occlusion and
orofacial pain conditions is likely to be associated
with the orthopedic instability of the masticatory
system.
The assessment of the orthopedic instability of
the masticatory systems begins with an occlusal
evaluation when the condyles are in the most
musculoskeletal stable position. This position is
achieved when the TMJ condyles are located in
the most superior and anterior position in the
mandibular fossae, against the posterior slopes
of the articular eminences, with the discs properly
interposed (also termed, centric relation). In this
position, the mandible can then be purely rotated
opened and closed approximately 20 mm
interincisally, while the condyles remain in their
musculoskeletal stable position.
In order to guide the patient to a musculoskel-
etal stable position the patient should be
approached in a soft, gentle, reassuring, and
understanding manner. The patient should be as
relaxed as possible lying on the back with the
chin pointed upward. Lifting the chin upward
places the head in an easier position to locate
the condyles near the superior and anterior posi-
tion (Fig. 20a). The clinician sitting behind the
patient should place the four fingers of each hand
on the lower border of the mandible with the
smallest finger behind the angle of the mandible.
It is important to locate the fingers over the bone
and not in the soft tissues of the neck. Next, both
thumbs are placed over the symphysis of the chin
so they touch each other between the chin and
the lower lip. When the hands are in this posi-
tion, the mandible is gently guided by upward
force placed on its lower border and angle with
the fingers, while at the same time the thumbs
press downward and backward on the chin. The
overall force on the mandible is directed so the
condyles will be seated in their most superior and
anterior position braced against the posterior
20
Fig. 20 A manual procedure to locate the most musculos-
keletally stable position of the TMJs. (a) The patient is
reclined and the chin is directed upward. (b and c) The four
fingers of each hand are placed along the inferior border of
the mandible with the small fingers behind the mandibular
angle. (d and e) The thumbs meet over the symphysis of the
slopes of the eminences. Firm but gentle force is
needed to guide the mandible so as not to elicit
any protective reflexes (Dawson 1989;
Fig. 20b–e).
The movement begins with the anterior teeth
no more than 10 mm apart to ensure that the
J.P. Okeson and I. Moreno Hay
chin. Mild and controlled force is directed downward on
the chin while applying superior and anterior force at the
angle of the mandible. These combined forces direct the
condyles into the most superior-anterior position in the
fossae
temporomandibular ligaments have not forced
translation of the condyles. The mandible is posi-
tioned with a gentle arcing until it freely rotates
around the musculoskeletal stable (CR) position.
This arcing consists of short movements of 2 to
4 mm. The occlusal contacts are then verified by
Clinical Evaluation of Orofacial Pain
means of an articulating paper or alternatively
with Shim stock (0.0005-inch-thick Mylar strip).
If orthopedic stability is present, the teeth
should occlude in the maximum intercuspation
with no slide or less than 2 mm. Only discrepan-
cies of more than 2 mm between the orthopedic
musculoskeletal stable position and the maximum
intercuspation are defined as orthopedic instabil-
ity. The clinician should be aware that the pres-
ence of a significant shift does not in itself
represent an etiology of orofacial pain. Most
patients with significant shifts have no pain
symptoms.
In some instances, patients might complain
from a sudden change in the intercuspal position
directly related to a functional disturbance. The
patient is fully aware of this change and can be
induced by muscle disorders and intracapsular
disorders. This is known as an “acute malocclu-
sion” (Okeson 2013a). When this occurs, the cli-
nician needs to appreciate that this malocclusion
is not causing the disorder but is a result of the
disorder.
Muscle spasms and protective co-contraction
are muscle disorders that can alter the postural
position of the mandible. When this occurs and
the teeth are brought into contact, an altered occlu-
sal condition is felt by the patient. For example,
spasms of the inferior lateral pterygoid cause the
condyle on the affected side to be pulled anterior
and medially, resulting in open bite between the
posterior teeth on the ipsilateral side and heavy
anterior tooth contacts on the contralateral side.
Regarding the intracapsular disorders, a rapid
change in the relationship of the articular surfaces
of the joint can create an acute malocclusion, for
example, in retrodiscitis which is a condition that
separates the bony structures inside the TMJ due
to inflammation or trauma. In this instance, the
ipsilateral posterior teeth may not contact and the
contralateral posterior teeth may contact heavier.
Moreover, no pain or discomfort should be
elicited during the occlusal evaluation. If pain is
produced, it is likely due to an intracapsular dis-
order exists, as a result of loading the retrodiscal
tissues. Since these symptoms aid in establishing
a proper diagnosis, they are important and are
therefore recorded.
21
It should be noted that when an acute maloc-
clusion is present, the clinician needs to deter-
mine what has caused the acute change in the
bite and not attempt to blame this on producing
the disorder. In most instances, when the cause
of the acute malocclusion is identified and elim-
inated, the occlusion will return to its normal
relationship.
Conclusions
The ultimate goal of every clinician is to help
eliminate, or at least alleviate, the patient’s chief
complaint that brings him or her to seek care. This
can only be accomplished by understanding the
precise problem causing the patient to suffer.
Establishing the correct diagnosis is essential for
selecting the most appropriate treatment strategy.
However, in the head and neck, pain can be a very
complicated problem. Therefore, it is essential
that all the information needed to establish the
correct diagnosis is acquired and evaluated. This
chapter has highlighted the manner by which this
information can be gained through a proper his-
tory and examination procedure. These skills are
basic and essential to successful pain
management.
Cross-References
▶ Arthritic Diseases Affecting the TMJ
▶ Biopsychosocial Considerations for Orofacial
Pain
▶ Burning Mouth Syndrome
▶ Classification of Orofacial Pain
▶ Headache
▶ Internal Derangements of the Temporomandib-
ular Joint
▶ Masticatory Muscle Pain
▶ Neuropathic Orofacial Pain
▶ Neurovascular Orofacial Pain
▶ Oral Appliance Therapy for Sleep Disordered
Breathing
▶ Orofacial Pain and Sleep
▶ Orofacial Pain Associated with Oral Mucosal
Disease and Cancer
22
▶ Orofacial Pain in the Medically Complex
Patient
▶ Sleep Bruxism
▶ Sleep Medicine for Oral Medicine Specialists
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