• Finally, dynamic tests are used to differentiate clicking sounds in the joints.
138 Reverse side of form
This side has spaces for all the information necessary for the tissue-specific examination of the extra-oral portions of the masticatory system. Entering the individual findings with a defined color-coding system allows a quick and convenient overview of which structures are adapted and which are not, as well as the corresponding loading vectors.
Patient History
The patient history is the foundation and a prerequisite for the diagnosis and treatment of functional disturbances. Together with the examination findings, it is used primarily in attempting to identify all regions of the masticatory system that have undergone structural damage (Okeson 1998). It serves further to help recognize the necessity for additional therapeutic measures and should protect both the patient and the clinician from failure (Nilges 1996). The history should be taken with the patient sitting upright in a quiet, relaxed atmosphere, ideally away from the treatment room.
As a rule, the general history can be adequately elicited by using a questionnaire. Eye contact and a friendly, interested demeanor on the part of the clinician promotes body language that will enhance nonverbal communication. If the patient’s descriptions become too long-winded, the clinician should politely interrupt and guide the discussion back to the relevant main questions of the specific history and the most prominent current symptoms. By repeating and summarizing the patients comments, the interviewer can help avoid misunderstandings.
139 General patient data
To the left of the examination form heading is a box for the imprint data from the patient’s insurance card. To the right, under the recording date, the patient is to check one or more of the main symptom groups.
The procedure followed for the specific history is based upon the assumption that the dentist is able to recognize symptoms in his/her area of specialty and reproduce them at will. In the introduction we identified two major divisions of the diagnostic phase:
• “What does the patient have?” or “Is a loading vector pre sent?” and
• “Why does the patient have this loading vector?” or “Are corresponding occlusal influences present?”.
Without evidence of a loading vector or, to put it another way, without the ability to repeatedly demonstrate a lesion that causes local or projected pain, there is no rationale for dental treatment, contrary to what was often previously assumed. Therefore all questions related to the “why?”, that is, concerned with influences, should at first be strictly avoided in taking the specific history. Background inquiries into possible causes and previous therapeutic considerations (e.g. descriptions of the psychosocial environment, psychological questionnaires, detailed descriptions of previous treatments, etc.) are usually very time-consuming. Therefore a structured, symptom-related, tissue-specific examination is preferred. If the reported symptoms cannot be reproduced by this, then the patient must be referred for evaluation of systems in other fields such as orthopedics, neurology, psychology, or otolaryngology. If, on the other hand, the symptoms can be provoked, a search for possible causes and influences is conducted. A basic rule following from this is to concentrate ones efforts on those patients for whom dental procedures seem reasonable as a primary or supplemental treatment.
For this targeted, clinically appropriate interview process, three main questions have proven useful over the past few years:
“What are the Complaints that Brought You to Me?”
A meaningful entry in the specific history is an exact description by the patient of the presenting symptoms. Here the patient will usually report symptoms such as pain, restricted movement, clicking sounds in the joints, tinnitus, vertigo, burning tongue, lump in the throat, or a nonspecific sensation of pressure and tension. If the patient exhibits only one symptom, the course of the specific history will usually be relatively simple.
Whenever a pain symptom is reported, special attention must be given to its location, characteristics, initial occurrence, and the factors that increase its severity. The more vaguely a patient localizes the pain, the more specific the examiner’s inquiry must be and the more strongly he must encourage the patient in his or her account. Pain that is described as localized and sharp, unlike dull, widespread pain, is quite unreliable for differentiating between arthirogenic and myogenic disturbances. Nevertheless, the precise localization of pain, and especially an account of whether a larger area of pain is provoked by one or more localized pains, is of great importance for the later progress of the examination.
If an area of pain extends from the angle of the jaw to the temporal region, the examiner must clarify:
• whether the problems all come from one point and spread out over the entire affected region or
• whether one part of the pain comes, for example, from a point in front of the ear and radiates into the temporal region while another part is caused by a “different” pain directly in the region of the angle of the jaw. In this case the clinician is dealing with two separate pains that just happen to be close together.
140 Special history
This section of the questionnaire is especially for patients with functional disturbances. It is essential that each patient answers the questions to his symptoms and his expectations. They can be supplemented as needed for individual cases. The answers to these questions will determine the precise course of the examination as well as the type and extent of therapeutic measures to be introduced.
This distinction has definite consequences for the examination procedure that will follow as well as for the treatment. If one wishes to completely eliminate the patient’s symptoms when the pains are separate, one must be able to elicit two pains that differ in their quality and location during the tissue-specific loading of the individual structures. If, for example, only one of the multiple pains reported in the patient history can be provoked, it will probably not be possible to rid the patient completely of all symptoms through dental treatment alone.
Therefore the fundamental rule is that if a symptom reported in the patient’s history is to be eliminated through dental treatment then one must be able to repeatedly reproduce it during the course of the tissue-specific examination. An analogous practice is followed in the diagnosis of pulpitis: If the pain described by the patient cannot be reproducibly provoked and no lesion (such as caries) can be detected, one would not normally proceed with endodontic treatment.
After the patient has described his or her complaints more accurately the dentist summarizes the information once more and concludes by inquiring about other symptoms. For example: “If I understand you correctly, you have pain on the right side in front of the ear and at the angle of the jaw. Beyond that you have no other problems. There is no clicking in the joints, and you can always open your mouth as far as it is supposed to go. Is that correct?”
“Rank Your Problems in Order of Severity”
When multiple symptoms are reported the patient is asked to rank them according to their impact on his/her well-being
