1. Condyle tenderness which is equal to or greater than 2 on a 0 to 3 scale and which is more pronounced than ipsilateral anterior temporalis and superficial masseter tenderness indicates temporomandibular joint capsulitis. Patients with this finding are very likely to express TMD symptoms which are driven by temporomandibular joint-specific inflammation and/or mechanical deformation.

2. Tenderness of the belly of the sternocleidomastoideus and/or upper trapezius may be produced by inflammation of the temporomandibular joints. This can be unilateral, bilateral or ipsilateral to the involved joint. These muscles are almost always hypertonic as well as tender if temporomandibular joint inflammation is the driving force behind this finding. This indicates that this is not just referred pain, but a muscular reaction to heightened neurologic activity produced by joint inflammation. This has been confirmed by retrospective surgical testing (70,105) and anesthetic injection studies (17, 105).

3. Temporomandibular joint inflammation produces substantial hypertonicity and tenderness of the paracervical musculature especially in the suboccipital region. It may also cause hyper-contraction and tenderness of the scalene muscles with associated pain and paresthesia in the upper extremities.

4. Temporomandibular joint inflammation does not usually cause isolated tenderness of the spinous processes and interspinous spaces in the cervical region. This helps to differentiate primary cervical injury/pathology from temporomandibular joint-cervical affect.

5. The stylomandibular ligaments and the temporal tendons at their coronoid attachments should also be palpated. Referred pain from the coronoid attachment includes the eye, bridge of the nose, temporomandibular joint and ear (101). Stylomandibular ligament inflammation refers pain to the preauricular region, ear, neck and head (101).

6. The mastoid processes are useful control areas for palpation. Except for mastoiditis or a direct blow to the area, this region is nontender in most all patients (severe temporomandibular joint inflammation may produce slight tenderness in a few patients). This area is above the sternocleidomastoideus insertion and lateral to the upper trapezial insertion. This is an area of thinly covered bone and, while not identical to the temporomandibular joint condyle, is similar. It thus provides an ideal area for comparison of palpation responses. The area should be palpated two to three times during the examination with the same pressure (3-5 pounds of pressure applied with the pad of the index finger). This allows the doctor to check for consistency of response. This is a valuable screening test for hypersensitivity, false complaint and malingering.

1. RESISTED PROTRUSION/LATEROTRUSION. To perform resisted protrusion, place your thumbs on the point of the patient's chin and your other fingers on the sides of the mandible for stability. Have the patient push the mandible forward with a force equal to your resistance. No joint movement should occur. If pain is produced, the inferior head of the external (lateral) pterygoid muscle is implicated. The pain will occur on the side of the involved muscle and may radiate to the temporomandibular joint, ear and/or cheek. This muscle does attach to the joint capsule and condyle and may stimulate true arthrogenous symptoms. Any headache or neck pain produced should lead one to suspect joint involvement. The internal (medial) pterygoids are also activated during this test, although to a lesser extent. The pain pattern is very similar to the external pterygoids, although pain is frequently felt at the angle of the mandible as well.

   By moving the thumbs slightly to the side of the chin and having the patient push the mandible against the thumbs, each lateral pterygoid (inferior head) can be tested for strength and/or isolated for involvement in pain production. When performing these tests be careful that the patient does not push the head forward as this win involve the cervical region and confound the results.

2. PASSIVE MANDIBULAR DISTALIZATION. The goal of this test is to press the condyles to the back and/or superior aspects of the fossae. If there is inflammation in the retrodiscal tissue or the superior/posterior articular surfaces, pain may be elicited. If this test is positive, severe inflammation of this region is indicated. Pain may be local to the involved joint and/or referred to the head, ear, neck and shoulders. This test has two limitations. First, inflammation may be predominantly in other areas of the joint and secondly, the external pterygoid inferior head may splint and prevent true compression despite the patient's attempt to relax and allow you to press the condyles back into the fossae. As a result, there may be substantial joint inflammation even when this test is negative. There are two popular techniques for performing this test:

1. The doctor faces the patient while the patient is either seated or supine. The doctor places his or her thumbs on the point of the chin and the second and third digits of each hand on the sides of the jaw. The doctor then places the fourth and fifth digits of each hand under the angles of the mandible. The patient pushes the mandible slightly forward against resistance and then relaxes. While the mandible is relaxed have the patient open their mouth approximately one-third of the way. Slowly push back on the chin while lifting up under the angles of the mandible as the patient keeps the jaw relaxed. The doctor alternates from straight anterior/posterior pressure to pressure toward one joint and then the other. During this procedure you may notice that the patient's muscles, specifically the inferior heads of the external pterygoids, may resist your attempt at distalization. To adjust for this, have the patient repeat protrusion while you resist the attempt and then as the patient relaxes per your instructions once again distalize the mandible and press upward into the fossae.

2. The doctor stands behind the seated patient and interlaces his or her fingers cupping them under the patient's chin. The patient rests the back of their head against the doctor's torso if a standard chair is used or against the headrest of a dental chair if one is available. The patient then relaxes and opens the mouth approximately one-third of the way. The doctor then slowly pulls up and back pressing the condyles into the joint. The doctor has great mechanical advantage during this technique and must be careful not to injure the patient.

Local jaw pain and/or referred pain, especially to the ears, suboccipital region, neck and shoulders, signals a positive result for this test. A positive result on this test, especially when resisted protrusion was negative, is a strong indication of substantial temporomandibular joint inflammation most likely in the posterior and superior aspects of the involved joints.

3. JOINT LOADING DURING PROTRUSION. This technique is used to test for inflammation in the anterior aspect of the temporomandibular joints (condyle against posterior slope of the eminence with or without disc intervening). To set up for this test stand behind the seated patient. If the patient is seated in a dental chair, they can place the back of their head into the headrest of the chair. If the patient is seated in a standard chair, the test is best performed by having the patient rest their head against your torso. Place your hands underneath the body of the mandible from the mid body back to the angles and lift up gently, bringing the condyles to the upper portion of the joints. Instruct the patient to separate the teeth only slightly and then protrude the mandible. This should occur without the teeth touching. Stop immediately if pain is produced or joint locking occurs. This is a particularly threatening test and should be performed with caution. Prior to performing the test instruct the patient to stop any attempted protrusion at the first sign of pain and/or locking. This way, any possibility of aggravating the condition may be minimized.

Pain in the involved joint and/or pain referred to the ears, head, neck or shoulders signals positive result. Other positive findings include increased volume of clicking or frank locking as the condyle catches behind an anterior adhesively restricted disc. Pain and locking together during this test signals a disorder with a guarded prognosis for conservative resolution.

4. DISTRACTION OF THE TEMPOROMANDIBULAR JOINTS. This test may be performed with the patient seated or supine. Some doctors perform this test one joint at a time and others use a bilateral technique.

Bilateral supine technique: Have the patient lie supine and position your body to face cephalad. Have the patient open his/her mouth and then lean forward placing your thumbs over the mandibular teeth. Grasp the undersurface of the mandible with the remaining fingers of both hands. Having grasped the mandible firmly press down with the thumbs effectively pulling the condyles away from the superior portion of the fossae. Pre-instruct the patient to point to any areas of pain that may occur as you perform the test. This technique stretches the muscles as well as distracts the joints. Thus, the patient may point to any number of areas. Pain in the joints is indicative of temporomandibular joint inflammation (capsular and/or inflamed intra-articular scarification). Pain in the masticatory muscles may indicate a myofascial problem such as a trigger point, although masticatory muscle contraction secondary to temporomandibular joint inflammation may produce the same result. The most common positive finding for temporomandibular joint inflammation, however, is local temporomandibular joint pain. A positive finding for joint inflammation should discourage any temporomandibular joint manipulation until the acute phase is controlled.

5. CLENCH ON SEPARATORS. Clenching the teeth together (when a full complement of teeth is present or missing teeth have been effectively replaced) for a few seconds upon command should not cause the patient pain. Pain produced may be odontogenic (including the periodontal ligament), muscular or arthrogenous. Suspected tooth pain can be investigated by having the patient place cold and/or hot liquids in the mouth as well as by percussion of the teeth as positive findings on these tests tend to be indicative of odontogenic problems. If the examining doctor is not a dentist, referral for a complete dental exam is recommended. Non-dental pain may be myogenous or arthrogenous. Differential diagnosis between muscular pain and the pain of joint inflammation is aided by having the patient clench and/or chew on separators (items placed between the upper and lower teeth). Some doctors use soft wax for this, however cotton rolls will suffice. Pain produced when the patient bites down on cotton rolls which have been placed between the teeth bilaterally is most frequently of muscular origin. Joint inflammation may be implicated in certain cases, however. This may be due to the effect of joint inflammation on the muscle tissue reflexively. When separators are placed unilaterally, the mechanics and interpretation of the test are more complex. This test can be described by example. If the cotton roll is placed between the upper and lower teeth on the right and the patient has pain with biting down the following guidelines apply: Ipsilateral pain indicates probable myofascial component with possible joint inflammation on the side of pain; contralateral pain, especially pain in the temporomandibular joint or ear, strongly suggests temporomandibular joint inflammation on the side of pain. This is because unilateral biting onto an object (whether a bolus of food or cotton roll) compresses the contralateral joint and not the ipsilateral joint (4).

In summary, provocation tests can help to clarify the diagnostic impression. As the tests are provocations of potentially damaged tissues they should be performed carefully and not repeated routinely. They should be used during reexamination only if the case is not progressing satisfactorily and the diagnosis needs to be challenged. These tests are indicators of diagnostic probability and do not stand alone as definitive.

1. Specific diseases, tumors and fracture aside, x-rays of the temporomandibular joints cannot identify the presence, past history or predicted future course/development of a temporomandibular disorder (26).

2. Alterations in bone morphology (as observed on x-ray) may occur as a result of successful remodeling of the temporomandibular joints (83). Alterations in condyle/fossa shape should not be interpreted as indicating degeneration unless signs and symptoms of a joint-specific disorder are present. Even then, the x-ray findings may be incidental. This includes plain films, tomography, transcranials and the panelipse.

3. Corrected positional tomograms can be used to assess a predisposition to anterior disc position. This references the tendency of the condyle to sit behind the disc during maximum intercuspation if the condyle is seated in the posterior/ superior aspect of the fossa. This information can be very useful in case management of the patient with symptom expressive internal derangement. Medical laminographs taken with the patient lying down cannot provide this information.