6 Evaluation of the destruction
The extent of intraoral destruction is determined by the traditional dental primary diagnostic methods. Damage to the individual structures of the temporomandibular joint and the muscles of mastication can be detected only through manual functional analysis. In some cases additional imaging procedures are necessary.
Left: Example of a clinical examination technique (posterosuperior compression) to detect destructive changes in the masticatory system.
7 Identification of the impediments
Identification of musculoskeletal impediments is very important for treatment planning. If existing impediments are not diagnosed, the treatment goal will be reached much later, if at all. Furthermore, the treatment result is likely to remain unstable.
Left: A histological slide shows anterior disk displacement with disk deformation as an example of an impediment in the anterior treatment direction.
8 Identification of the influences
The search for causes is aided by asking why the symptom arose. From the dental point of view, the question arises as to whether the with the symptom or the loading vector (see p. 124ff). If this is not the case then the patient in question will not be helped by modifications of the occlusion.
Left: Example showing use of the Mandibular Position Indicator to help diagnose a static occlusal vector(see p. 128).
The Role of Dentistry in Craniofacial Pain
Polarizing discussions during the past 10 years have made the role of the dentist in diagnosing and treating pain in the head and neck region increasingly obscure rather than more clear. In the academic debate concerning the etiology-predominantly psychological factors versus predominantly occlusal factors—the practitioner facing the problem of treating a patient has been largely ignored. The argument of multicaiisal genesis was previously taken as an excuse to regard the multiple causes as an inseparable bundle rather than to dispel at least a certain amount of confusion by specifically testing the individual factors.
It is our opinion that every patient with head and neck pain should be seen by a dentist in order to clarify the following questions:
• Do the symptoms arise from a structure in the masticatory system (presence of a loading vector)?
• Is the loading vector related to the occlusion?
• Can the occlusion-related portion of the total loading vector be reduced with reasonable effort and expense?
• Would symptomatic treatment in the dental office be reasonable?
9 Differential diagnosis of head and neck pains
A pain classification scheme modified from those of Bell (1990) and Okeson (1995). The colors of the backgrounds of the different diagnoses indicate which disorders are outside the realm of dental treatment and which require the inclusion of Other disciplines for diagnostic assistance or for ruling out certain conditions. In addition, colors indicate which diagnoses can be arrived at through which steps in the dental examination. As clearly shown by the overview, dentistry covers a significant part of the differential diagnosis of head and neck pain. This does not mean, however, that dentistry should be the leading discipline in treating every case of head and neck pain. There are, for example, areas in which the dentist cannot intervene with primary cause-related treatment, or even with interdisciplinary secondary support. The primary goal of a tissue-specific diagnostic process for identification of loading vectors is to differentiate between conditions that can and cannot be treated by a dentist. Except in the latter instance, the decision must then be made whether dentistry is to provide the sole treatment of the diagnosed conditions or is to be part of an interdisciplinary approach.
Primary Dental Evaluation
The dental examination is the conditio sine qua non for arriving at a correct diagnosis and effective dental treatment plan. Every case in which a patient complains of craniofacial pain requires a thorough gathering of information on the status of the teeth, periodontium and mucous membranes, even when there appears to be no connection between the reported complaints and the “typical” toothache. Beware of a superficially conducted “quick diagnosis” which always increases the risk that essential findings and secondary factors will be overlooked, incorrectly evaluated, or forgotten, especially when they seem to bear no apparent relationship to the patient’s reported symptoms.
Strictly speaking, the examination begins with the first visual and verbal contact with the patient (physiognomy, skin and facial coloration, posture, gait, speech etc.) Even if not all the information is germane to the dental diagnosis, it is the dentist’s duty to identify, to the best of his or her ability, any symptoms that might indicate a systemic illness and to motivate the patient to seek an evaluation from an appropriate specialist (Kirch 1994).
There are various techniques for eliciting and documenting a case history. It is recommended that patients first be allowed to begin describing their history of illnesses in their own words. Because the description of previous illnesses usually proceeds at an irregular pace, after a period of time determined on an individual basis, the caregiver should politely interrupt the patient’s monologue and conduct the consultation further by asking concrete questions concerning the primary and secondary symptoms. Under no circumstances should these questions be leading or suggestive. The diagnosis, treatment plan, and success of the treatment are dependent upon correct interpretation of the findings and therefore upon the knowledge and experience of the clinician. A frequent mistake is the failure to discuss not just the physical, but also psychological conditions as possible etiological factors, especially in cases with ambiguous, indistinctly localized complaints in the face and jaws (Marxkors and Wolowski 1998).
10 Special patient-history excerpt from the questionnaire “Manual Functional Diagnosis”
Findings in the Teeth and Mucous Membrane
The intraoral evaluation includes in particular:
• careful evaluation of the mucous membranes
• determination of the status of the teeth, including detection of caries and periodontal disease
• a search for signs of occlusal disturbances and parafunction (abrasion, wedge-shaped defects, enamel cracks and fractures, and increased tooth mobility) and
• evaluation of the function of fixed and removable partial dentures and orthodontic appliances.
Numerous diseases, both local and systemic, reveal themselves through changes in the oral mucosa. Therefore the lips, entire vestibule, alveolar ridge, hard and soft palate, tonsils, pillars of the fauces, oropharynx, floor of the mouth, and tongue, including its ventral surface, must be carefully examined for any rashes, discolorations, coatings, or indurations (Veltman 1984). Inflammation localized within the pulp, periodontium, or mucosa can cause pain, varying in degree from light to excruciating, to radiate to the jaws, cheeks, eyes, or ears. The pain can be accompanied secondarily by discomfort in the joints and muscles and by reduction of lower jaw mobility. In these cases, treatment is focused upon elimination of the primary cause of the pain. In those cases in which it is difficult to differentiate among the overlapping symptoms, selective introduction