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Centre for Evidence-
Based Medicine

Diagnosis: Clinical Scenario

Anita Gross, Ted Haines, Diane Hartley.
Contact Details: Anita Gross fax (905) 521-5090

A 24 year old woman with a gradual onset of left temporomandibular joint (TMJ) pain after yawning 10 days ago, reports severe worsening over the past 5 days resulting in a change to a soft diet. Her past history reveals recurrent episodes of jaw joint locking. Clinical findings are reduced mouth opening (maximum active opening 35mm, passive opening 36 mm), right laterotrusion (5mm) and a reproducible reciprocal click (early on opening and late on closing). There is no crepitus. Some local muscle tenderness exists (masseter, medial pterygoid). There is reduced joint play. Tomography results in the medical record demonstrated diminished anterior translation of both condyles. No osseous changes were noted. The clinical impression is internal derangement. You wonder if your diagnosis is correct, so you develop the following question and make plans to search MEDLINE:

"Is your clinical impression of temporomandibular joint disorder (internal derangement) correct for your patient with the following clinical [history of locking, preauricular pain, reproducible and reciprocal click, local muscle tenderness, reduced joint play, reduced mouth opening (35 mm) plus tomography findings (diminished anterior translation of both condyles, no osseous changes)? Is this diagnostic impression important for clinical management?"

You do a MEDLINE search (1988 - 1998) using the MESH heading 'temporomandibular joint disorders' and find one article assessing a cluster of clinical tests and tomography.

Schiffman EL, Anderson GC, Fricton JR, Burton K, Schellhas KP. Diagnostic criteria for intrarticular temporomandibular disorders. Community Dent Oral Epidemiol 1989;17:252-257.

Read the article and decide:

  1. Is the evidence from this study valid for the clinical diagnosis?
  2. If valid, is this evidence important?
  3. If valid and important, and if your patient was shown to have internal derangement can you apply this evidence in caring for your patient?

Continue to completed worksheet