Clinical Anatomy 13:9496 (2000)

Anatomical Knowledge and Clinical Evaluation of the Muscles of Mastication

J.A. KIESER1*
1Department 2Department

AND

G.P. HERBISON2

of Oral Sciences and Orthodontics, School of Dentistry, University of Otago, Dunedin, New Zealand of Preventive and Social Medicine, School of Medicine, University of Otago, Dunedin, New Zealand

In this survey, we identify the positive role that an instructional anatomy course has prior to a workshop on temporomandibular dysfunction. Not only did it result in enhanced clinical evaluation of the muscles of mastication acquired by the participants, but it also approximated the skills of dental and medical practitioners. Clin. Anat. 13:9496, 2000.
2000 Wiley-Liss, Inc.

Key words: temporomandibular joint; muscles of mastication; clinical anatomy

INTRODUCTION
Temporomandibular disorders (TMD) are a common and heterogenous group of clinical conditions characterized by pain in the muscles of mastication and of the neck, limitations in jaw movement, and various joint sounds (Dworkin and Massoth, 1994). Although it is generally agreed that the etiology of TMD is multifactorial, hyperactivity of the muscles of mastication has emerged as the most frequently cited causal factor (Lafreiniere et al., 1997; Gil et al., 1998). A number of workers have also underlined the role of stress in the generation of muscle hyperactivity (Scott and Gregg, 1980; Gray et al., 1995). Much of the current interest in the relationship between stress and muscle activity centers on diagnosis and treatment planning. In particular there is continuing emphasis on the value of a multidisciplinary approach to TMD (Mohler and Tarrant, 1991; Gil et al., 1998), whether it is caused by stress, muscle hyperactivity, malocclusion or parafunctions. Because a thorough physical examination of the patient remains dependent upon a sound knowledge of anatomy (Monkhouse, 1993), we felt that anatomy should be a major adjunct to our clinical TMD workshops. The purpose of this report is not so much to address the treatment of TMD, but to investigate the levels of diagnostic skills in a multidisciplinary setting. In particular we are interested in how basic anatomical instruction can enhance diagnostic skills of dental and medical practitioners who attended clinical workshops on TMD.

MATERIALS AND METHODS

General medical and dental practitioners were invited to attend a continuing education workshop on the diagnosis and management of temporomandibular joint (TMJ) disorders. Before the commencement of the workshop, practitioners were asked to perform clinical examinations on one another. Specifically, their skills at examining the four major muscles of mastication (temporalis, masseter, medial- and lateral pterygoids) were evaluated by the instructor. Skills chosen for assessment were the bimanual palpation of masseter, the extra-oral palpation of the origin of temporalis, and the response to resisted movement by the pterygoids. Each was scored by a single observer (JK) on an ordinal scale, with a score of 1 for no knowledge at all of the muscles of mastication, 2 for the ability to palpate correctly a single muscle. The highest score, 5, was assigned to practitioners who were able to palpate all four muscles of mastication. The TMJ workshops were divided into two groups, one which started with an hours illustrated lecture on the basic anatomy of the muscles of mastication and the other, which launched straight into TMJ dysfunction, its diagnosis, causes, and management. Equal numbers of dental and medical practitioners were
*Correspondence to: J.A. Kieser, Department of Oral Sciences and Orthodontics, School of Dentistry, University of Otago, PO Box 647, Dunedin, New Zealand. E-mail: jules.kieser@stonebow.otago.ac.nz Received 1 September 1998; Revised 4 November 1998

2000 Wiley-Liss, Inc.

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assigned to both workshops: Group I (with anatomy instruction), 13 dental, 11 medical; Group II (without anatomy instruction), 12 dental, 12 medical. The same material was presented in a similar manner in each workshop and those who had received the anatomy course were frequently advised to recall what they had learned earlier that day. At the end of each 1-day workshop, participants were again asked to perform clinical examinations of the same muscles of mastication and were evaluated on the same scale by the same instructor.

effect on diagnostic skills, an ordinal logistic regression analysis for the three variables was performed. The results point to a significant effect of the availability of anatomy instruction on the diagnostic skills acquired by practitioners at the end of the TMJ course. These results were not significantly affected by the practitioner type, and save for the temporalis and masseter (P 0.05), also not by muscle type.

DISCUSSION
The aim of this study was to see if basic instruction in the anatomy of the muscles of mastication would enhance the clinical skills of dental and medical practitioners who attended a workshop on TMD. Both dental and medical students receive their undergraduate anatomy instruction in a single year, with only the dental students being given subsequent reviews of the anatomy of the head and neck (Fitzgerald, 1992; AACA, 1996). There has, however, been a welldocumented shift in curriculum emphasis from classical didactic anatomy teaching to subjects such as molecular biology, biochemistry, and microbiology. Yet it has been shown that successful treatment of TMD is dependent upon an adequate knowledge of the osteology, soft tissue relations, and the biomechanics of the muscles of mastication (Gray et al., 1995). The principal muscles of mastication are the temporalis, masseter, medial- and lateral pterygoids. Because

RESULTS
Summary statistics for diagnostic scores of medical and dental practitioners before the course are given in Table 1. It is evident that the medial and lateral pterygoid muscles presented the greatest diagnostic challenge, particularly to medical GPs. When these data were analyzed by means of an ordinal logistic regression (Greenland, 1985), it was found that the level of knowledge of these two muscles differed significantly between dentists and medical practitioners before the course. Table 1 also gives summary statistics of diagnostic skills in medical and dental GPs after completion of the TMJ workshop. Diagnosis of the lateral pterygoid remained the most problematic. To test whether practitioner type, an anatomy course prior to the workshop, or whether muscle type had a significant

TABLE 1. Summary Statistics for Diagnostic Skills of Dental and Medical Practitioners Before and After the Workshop Diagnostic score before Muscle Temporalis Masseter Medial pterygoid Lateral pterygoid Category Dental Medical Dental Medical Dental Medical Dental Medical 1 0 0 0 0 8.3 70.0 16.7 80.0 With anatomy 2 3 4 8.3 60.0 41.7 60.0 50.0 30.0 50.0 20.0 58.3 30.0 58.3 30.0 41.7 0 33.3 0 33.3 10.0 0 10.0 0 0 0 0 5 0 0 0 0 0 0 0 0 1 0 0 0 0 16.7 62.5 41.7 38.5 Without anatomy 2 3 4 16.7 37.5 33.3 50.0 50.0 37.5 25.0 60.0 50.0 50.0 58.3 37.5 33.3 33.3 33.3 0 33.3 12.5 8.3 12.5 0 0 0 0 5 0 0 0 0 0 0 0 0 Z scorea Practitioner Course 2.61 0.78 3.70** 3.04** 0.38 0.74 0.27 0.19

Diagnostic score after Muscle Temporalis Masseter Medial pterygoid Lateral pterygoid
aScore

Category Dental Medical Dental Medical Dental Medical Dental Medical

1 0 0 0 0 0 0 0 0

With anatomy 2 3 4 0 0 0 0 0 10.0 16.7 40.0 0 0 41.7 40.0 58.3 40.0 58.3 30.0 50.0 50.0 58.3 60.0 41.7 50.0 25.0 30.0

5 50.0 50.0 0 0 0 0 0 0

1 0 0 0 12.5 8.3 50.0 41.7 10.0

Without anatomy 2 3 4 0 37.5 25.0 50.0 41.7 37.5 50.0 60.6 25.0 37.5 58.3 37.5 33.3 12.5 8.3 29.4 50.0 25.0 16.7 0 16.7 0 0 0

5 25.0 0 0 0 0 0 0 0

Z scorea Practitioner Course 1.68* 1.34 1.56 1.59 3.50** 3.65** 3.90** 4.20**

1 worst, 5 best (all values are percentages); Z score of an ordinal regression testing for the effects of practitioner and course. * P 0.05; ** P 0.01.

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of their size and external location, most of the muscle mass of temporalis and masseter can be externally palpated. In contrast, the medial- and lateral pterygoid muscles are relatively inaccessible and cannot convincingly be evaluated by palpation. Hence these latter muscles need to be evaluated by examining their response to resisted movement. This requires detailed knowledge of their location, insertions, and modes of action. The findings of this study suggest that a course of instruction in the anatomy of masticatory musculature given at the start of a TMD workshop has a significantly positive effect on the diagnostic skills acquired by participants. Whereas diagnostic skills were found to differ significantly between medical and dental practitioners at the start of the workshop, the anatomy lecture allowed medical practitioners to match the levels of diagnostic skills acquired by dental colleagues at the end of the workshop. In the absence of such instruction, neither group benefitted, with paricularly the medial- and lateral pterygoid muscles remaining illdiagnosed. Our working hypotheses about the diagnostic skills of medical and dental practitioners were, first, that the former would have less basic anatomy knowledge about masticatory musculature than the latter, and second, that anatomical knowledge was imperative for the adequate diagnosis of TMD. In light of the evidence presented here, it is suggested that an introductory anatomy lecture not only allows for equalization of diagnostic skills between dentists and medical practitioners, but also enhances the overall diagnostic skills of both groups.

ACKNOWLEDGMENTS
The authors thank AMA for organizing and funding the workshops.

REFERENCES
American Association of Clinical Anatomists. 1996. A clinical anatomy curriculum for the medical student of the 21st Century. Clin Anat 9:7199. Dworkin SF, Massoth DL. 1994. Temporomandibular disorders and chronic pain: disease or illness? J Pros Dent 72:2938. Fitzgerald MJT. 1992. Undergraduate medical anatomy teaching. J Anat 180:203209. Gil IA, Barbosa CMR, Pedro VM, Silverio KCA, Goldfarb DP, Fusco V, Navarro CM. 1998. Multidisciplinary approach to chronic pain from myofascial pain dysfunction syndrome. J Craniomand Prac 16:1725. Gray RJM, Davies SJ, Quayle AA. 1995. Temporomandibular disorders: a clinical approach. London: British Dental Association. Greenland S. 1985. An application of logistic models to the analysis of ordinal responses. Biometrical J 27:189197. Lafrenie ` re CM, Lamontagne M, El-Sawy R. 1997. The role of the lateral pterygoid muscles in TMJ disorders during static conditions. J Craniomand Prac 15:3852. Mohler SN, Tarrant JD. 1991. Multidisciplinary treatment of chronic craniomandibular disorder. J Craniomandib Prac 9:2934. Monkhouse WS. 1993. Teaching and examining clinical skills in anatomy. Clin Anat 6:185187. Scott DS, Gregg JM. 1980. Myofascial pain of the temporomandibular joint: A review of the behavioral-relaxation therapies. Pain 9:231241. Yem MR. 1976. Neurophysiologic studies of temporomandibular dysfunction. Oral Sciences Rev 7:3139.