“What Exactly Do You Expect from Me?”
At the end of the history taking there is the question of the expectations the patient had in corning to the dentist. One patient might seek only an explanation of a troublesome symptom but no further treatment, another may expect thorough diagnostic procedures and complete treatment, while a third may want only relief of the primary symptom.
The patient’s expectations will have a substantial influence on the course of the examination and the treatment plan.
Taken together these three main questions of the specific history serve as a framework on which to organize the case presentation that will be given following the tissue-specific examination with manual functional analysis. This ensures that patients receive relevant information about the symptoms afflicting them and the answers to their questions.
Positioning the Patient
The position of the patient is an important condition for a specific examination and is different for each section of the examination:
• History taking is always carried out with the patient sitting upright.
• The examination procedures for manual functional analysis are performed from the 12 o’clock position, or more precisely, between the 11 and 1 o’clock positions. Three arrangements are possible, the choice depending upon the examiner, the patient, and the space available. These are:
a) The patient is semi-reclined with the backrest at about a 45° angle and the examiner is standing upright behind the patient.
b) The patient is supine and the examiner is standing upright.
c) The patient is supine and the examiner is seated (the most effective variation).
• Testing for harmful influences can be carried out with the patient either fully reclined or sitting upright.
141 Examiner standing and patient semireclined
This arrangement is equally comfortable for both the clinician and the patient. It is normally chosen if for any reason the examiner prefers to work standing up or if the patient cannot recline fully because of a general orthopedic problem.
142 Examiner standing and patient fully reclined
This horizontal positioning of the patient with the examiner standing is appropriate only if the clinician is of short stature. Otherwise it would be difficult to stabilize the patient’s head. Furthermore, a dental chair cannot normally be raised high enough for a taller clinician to examine the patient while maintaining an economically sound posture.
143 Examiner sitting and patient fully reclined
The most frequently used arrangement for a tissue-specific examination is with the patient reclined and first adjusts the height of his/her stool so that the thighs are parallel with the floor or are at an angle of approximately 95° from vertical. Finally the height of the dental chair is adjusted. During palpation of the temporomandibular joints the elbows should be bent at a 90Q angle.
Manual Fixation of the Head
In addition to the correct positioning of the patient, optimal stabilization of the patient’s head is an important condition for achieving reproducible results during the examination. Regardless of the patient’s position, it is essential that the head of the patient be supported in all spatial dimensions at all times. A good examination technique requires that forces applied to the mandible in different directions cause no noticeable movements of the head. Not only does optimal stabilization have a positive effect on the patient’s opinion of the examination procedure but it also has solid medical grounds:
• Aggravation of a preexisting problem within the cervical spine must be absolutely avoided.
• Protection of the cervical spine of a patient with diffuse headache or tinnitus is of diagnostic importance. Placing stress on the cervical spine can in some cases precipitate tinnitus. The examiner, however, because he/she is performing a “temporomandibular joint examination” might mistakenly assume that the cause is arthrogenic.
144 Clinician standing and patient semireclined
This combination allows the dynamic tests and the isometric contractions to be carried out quite reliably. However, optimal stabilization of the patient’s head is not always assured for the entire joint-play technique, and the clinician’s back is bent during a large part of the examination. For follow-up exams in which only a few manipulations are to be carried out, however, this position is ideal.
145 Clinician standing and patient fully reclined
Short clinicians who like to stand while working at the dental unit can achieve satisfactory stabilization for almost all examination techniques with this arrangement. If the examination is to take place on a treatment table with adjustable height, the headboard must be shortened to achieve adequate fixation of the head for the various techniques.
146 Clinician sitting and patient fully reclined
The ideal combination for reproducible examination results is a fully reclined patient and a seated examiner. All dynamic tests and isometric contractions can be performed from the 12 o’clock position. All joint-play tests are performed for the right joint from the 1 o’clock position and for the left joint from the 11 o’clock position. During almost all tests the patient’s head is stabilized in all three planes by the headrest, one of the clinician’s hands, and the clinician’s abdomen.
Active Movements and Passive Jaw Opening with Evaluation of the Endfeel
Examination of the extraoral portions of the masticatory system begins with observation of active jaw movements. Active movements do not contribute to the differential diagnosis (Szentpetery 1993), but serve only to document the initial conditions and to verify the symptoms described by the patient. Note is made of the extent of movements in millimeters and any accompanying pain and its location (right/left). None of this in any way supports a differential diagnosis but it does serve to test the conclusiveness of the reported symptoms.
Attention is given to any alteration in the path of movement of the incisal point (deviations and deflections) as has been recommended earlier (Wood 1979), but these are not documented. Because deflection to one side, for example, can have different arthrogenic causes (ipsilateral hypomobility or contralateral hypermobility), it makes more sense to determine the amount of condylar translation. This is done by palpating the lateral poles of the condyles during opening and protruding movements. Under normal conditions a condyle translates almost to the crest of the eminentia.
