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Nevynnyi Hennadii, Clinical resident, Bogomolets National Medical University
Nespryadko Valeriy, Doctor of Medical Science, Professor, Honored Worker of Science and Technology of Ukraine
Proshchenko Andrey, PhD., associate professor E-mail:
DEVELOPMENT AND EXPERIENCE OF APPLICATION OF THE MAP OF SUBJECTIVE AND OBJECTIVE RESEARCH IN THE DIAGNOSTICS AND AT THE STAGES OF ORTHOPEDIC REHABILITATION OF PATIENTS WITH CRANIOMANDIBULAR DYSFUNCTION (functional disorders of the musculoskeletal system)
Abstract: In this article is investigated a systemization and visualization of complaints and symptoms characteristic of the patients with craniomandibular dysfunction with the aim of making the initial diagnosis, planning additional examination methods and orthopedic treatment of patients with functional disorders of the dentofacial structure.
Keywords: prosthetics, functional disorders, occlusion, occlusion tooth contacts, bruxism, dysfunctional disorder of the masticatory apparatus, deviation or deflection of the mandibular, TMJ area.
Scientific innovation: according to the data provided by domestic and foreign authors, dysfunctional disorders of the dentofacial structure are one the most widely spread illnesses among the patients who come to visit a dentist, and occurs in 31-85% of all patients. According to the European Headache Federation, 80% of the population suffers from occasional tension-type headaches, which occur in the state of general muscle tension, particularly under stress. One of the signs of tension is unconscious teeth clenching, which may lead to pathological teeth clenching, which in turn may provoke the development of bruxism and dysfunctional disorders of the dentofacial structure.
Introduction. Lately, dentistry has been paying more and more attention to the ways the dentofacial structure disorders reflect on the general condition
of the patient, his postural status in order to carry out differential diagnostics based on the complaints of the patient with such illnesses as dysfunctions of the muscular-skeletal system, the blood vessels of the brain, the increase or decrease of the intracranial pressure, hypertension, primary headache etc. This group of patients requires an additional consultation and treatment of a neurologist, a vertebrologist, an ENT specialist, a medical psychologist. Quite often patients do not pay attention to certain symptoms and interpret them without relating them to the state of chewing. The majority of them do not suspect that they have some functional or morphological problems, which mask the true clinical picture due to the adaptive properties ofa body. Because ofthis a dentist must analyze the general condition, correlating it with the existing dental issues. Diagnosis ofhidden pathologies and in-
forming the patient about them is a primary necessity of the initial dental check up. Because of this, there occurred a need to create a medical card of subjective and objective check up of patients with cranio-mandibular dysfunction (functional disorders of the dentofacial structure) as the general medical card of a dental patient does not meet all the requirements for reflecting the state of the patient as well as the necessity to prescribe additional check-ups. There are tests for evaluating the presence of dysfunctional disorders, e.g. the Hamburg Test (KROGH-POULSENS); according to Ahlers M. O., Jakstat H. A., 2000, the algorithm of this test consists of 6 questions, the positive answer to which may signify a presence of a dysfunction. Using this test, we do not have the possibility to document the complaints, evaluate the clinical pattern in general. There is also a clinical index of dysfunctional disorders of Helkimo (1974) with the help of which a number of received points may be analyzed, but using this method only allows us to evaluate the severity of the dysfunction.
In our opinion, the most informative method in initial diagnosing is questionnaire survey of the complaints and symptoms of a patient. Of the existing content-based questionnaires which reflect the state of a dental patient Gadzhy Dazhaev's 2014-2015 may be singled out. It consists of the dental history, general medical history and the check-up of the patient. Using this questionnaire allows us to gather the maximum amount of medical information from the patient as well as eliminates the necessity to fill in basic medical documentation and additional data for related branches of dentistry. CID\Prof. R. Slav-icek's questionnaire of initial diagnosis should be singled out as the most informative one as it allows the evaluation of the general state of the patient and to determine dysfunctional disorders of the condilo-muscular complex as well as to evaluate it with the help of the occlusal index and to visualize the chronic toothache and the state of teeth.
We can undoubtedly presuppose that there exists an ideal questioning algorithm for the evaluation of
the state of a dental patient with the symptoms of dysfunctional disorders of the dentofacial structure. However, the necessity to not only gather the medical information but also to carry this information to the patient using the terminology that he/she would understand and be able to visually evaluate his/her condition made us develop this questionnaire.
Systemization of the subjective and objective data that signifies the presence of dysfunctional disorders of the masticatory system are the basis of the suggested study. The term craniomandibular dysfunction (CMD) regards the interrelation of the mandible and the scull base, which may be characteristic of patients with functional disorders as well as of healthy patients and those with the asymptomatic TMJ. While filling in the card of a craniomandibular patient, the possibility of visualization of subjective and objective data in the medical card of the patient is taken into account as the graphic demonstrations considerably simplifies the perception of the clinic condition both by the doctor and by the patient. This is important at the stages of diagnosing and orthopedic rehabilitation of the patients with the dysfunctional disorder of the masticatory apparatus. The process itself is influenced by many factors which are crucial for the result of the treatment. Such factors include the psycho-emotional state, domestic problems of the patient, other people or circumstances that influence the treatment process, e.g. the tendency of patients to forget the symptoms they had. Thus, documentation of complaints, symptoms and clinical stages of treatment considerably simplifies the dialogue with the patient, as well as the process of medical history taking and allows the doctor to understand the pathologies of the muscular system as well as structural disorders of the TMJ better.
The medical card for the patients with functional disorders of the dentofacial structure consists of two main parts, the subjective and the objective one, and is filled in during the initial consultation as well as at every visit in the course of the treatment process.
The first part (subjective) consists of two tables with questions and a graphic picture. The first table contains the criteria that are based on the complaints and symptoms of dysfunctional disorders. They refer to pain localization, its irradiation, facial numbness, clicking in the TMJ area and complaints regarding earache. The table is systemized in such a way that it minimizes the time spent on collecting the subjective and objective data as the key complaints may be ticked and their intensity evaluated on the 1 to 5 scale.
One of the most important features of the first table are 3 elements:
1) With the graphic image of localization of pain from 4 parts of body and head (Figure 1);
Figure 1.
2) With the graphic image of pain irradiation from the area of TMJ, from right and left part of the body (Figure 2);
Figure 2.
3) With the graphic image of zones of numbness of face (Figure 3).
Figure 3.
In the second table you can see 12 questions, that can help you to define reason of origin of complaints, state of a patient and motivation in further treatment are collected:
1) Did you feel a tiredness in the muscles of face, in especially the evening or after the protracted conversation or reception of meal?
- This question concerns the increase of fatigue of mussels with hyperfunction.
2) Did you feel lower jaw stiffness in the morning, after a dream?
- The essence of question consists in presence of reductions of muscels that results in hypertone during within sleeping that testifies the presence of night form of bruxism.
3) Did you notice that, while closing teeth, you try to find a comfort position of your teeth?
- Positive answer can testify the presence of premature contacts, force position of lower jaw.
4) Did you or your nearest ones notice night teeth grinding?
- Positive answer testifies bruxism.
5) Did you or your nearest ones notice snoring?
- Presence of snoring or sleep apnea gives an opportunity to admit the dislocation asphyxia as the consequence of hypertrophy, hypertone of masticatory mussels or distal position of lower jaw.
6) Do you feel the clench of teeth in the state of calmness?
- Positive answer testifies the presence of daily form of bruxism.
7) Have you ever had tracheal intubation?
- During the placement of endotracheal tube, lots of anesthesiologist try to open widely the mouth of the patient and as the result we can have the stretching of articular jaw, injuries of the ligaments and lateral pterygoid muscle and also dislocation of TMJ.
8) Have you ever extracted "wisdom teeth"? If so, when?
- This question is about the paratherapeutic injuring of area TMJ.
9) Have you ever had orthodontic treatment? When?
- In this question it is important to understand the role of change of occlusion on disfunction abnormalities.
10) Have you ever had the feeling "lump in a throat", or complications in pronunciation?
- Positive answer can testify the presence of hypertone and hypertrophy of muscels.
11) Do you consider your state as serious?
- This question shows patient's interest in further treatment.
12) How often are you in the state of stress?
- It is important to understand that stress provokes the spasm of muscles and it may influence on the process of treatment.
13) How do you see your emotional state?
- This question it is necessary to offer the next possible answers:
1. Anxiety is a normal reaction on a stress factor, but testifies its permanent presence (possible destructive influence on treatment);
2. Fear appears as the result of stress, that can lead to thoughtless decisions (causes destructive influence on treatment);
3. Anger is the directed aggression against someone (causes destructive influence on treatment);
4. Irritation as discrepancy of desirable above the reality, it is necessary to see the threat of discrepancy of imagination of patient to the process or result of treatment (causes destructive influence on treatment);
5. Calmness - ability of patient to get along with the stress even in the armchair of dentist (productive influence on treatment).
The answers on this question are necessary to examine previously in a context, because negative answer foresees the disparity of absence of stress with the presence of abovementioned emotions: anxiety, fear, anger or irritation.
14) Do you need treatment?
- final question that gives an opportunity to estimate patient's perception of the treatment and raise the level of motivation in the future treatment.
NB! You have to follow the abovementioned sequence of questions and their formulation after for expectation of objective answer by a patient.
An obligatory requirement is to observe the order of the questions and their phrasing in order to receive an objective answer from the patient.
Figure 4.
The second part (objective) contains a table for collecting the objective data, such a palpation of the masticatory muscles as well as the head and neck muscles, palpation of the TMJ in the position of central occlusion and while moving the mandibular, auscultation of the TMJ area, distance between the cutting edges of the maxilla and the mandibular in the position of maximum mouth opening. Moreover, the second part includes a picture of head and neck from the left and right sides (pic. 4) to enable the visualization of hypertension, hypertrophy, muscle segmentation, trigger pain points. The given image allows us to document the localization of trigger muscle points, to determine muscle segmentation. Attention should be drawn to the graphic scheme, which determines the visualization and documentation of mandibular movements while opening and closing the mouth, as it allows us to document either the deviation or deflection of the mandibular, excursion of articular heads of the mandibular while opening and closing the mouth at
the rotation or translation stage. At the beginning of filling in the scheme, the symmetry of the lower third part of the face (pic.5) is visually evaluated, in case of asymmetry the arrow which corresponds to the direction ofdislocation ofthe mandibular is coloured. It will then be necessary to mark the movement of the crossbite from the position of central occlusion to the position of maximum mouth opening (at the stage of mouth opening) either visually or with the help of a clinical clinometer. After that, using palpation, the symmetry of articular heads excursion while opening and closing the mouth is evaluated and either the sequence or the symmetry of the right and the left sides is documented in this very scheme. All the notes in this scheme are taken in the form of arrows the direction of which corresponds to the direction of the shift of either the crossbite or of the articular heads.
Figure 5.
Moreover, the second part contains the card of functional tooth contacts (Figure 6), which consists of five schematic images of the upper and the lower dentitions, each of the five schemes ensures the possibility to determine the existence of contacts in various conditions, monitoring of the contacts is carried out with the help of carbon paper (30 micron), wax occlusiogram: pict.
The centric relation tooth contacts (using the method of muscle deprogrammers (Pankey, Amann, Girrbach), the multi-sheet template etc.), bilateral manipulation (Peter E. Dawson) or the myostimulation apparatus (TENS);
Centric occlusion tooth contacts (centric relation or maximum intercuspidation);
Presence of occlusion blocks and hyper balancing supracontacts during the left-sided mediotrusive movement on the laterotrusive side;
Presence of occlusion blocks and hyper balancing supracontacts during the right-sided mediotru-sive movement on the laterotrusive side;
Presence of occlusion blocks and hyper balancing supracontacts during the forward movement (protrusion).
Figure 6.
Conclusion: The process of occlusion diagnostics in the articulator and the evaluation of the overall clinical state of the patient are simplified due to documentation of complaints, subjective and objective symptoms, their graphic visualization as well as the analysis of the gathered data, which in turn allows the doctor to give a more accurate initial diagnosis. Using the medical card of a craniomandibular patient allows us to better see and evaluate the clinical picture of the patient; the documentation makes it possible to go back to the discussion of the clinical picture of the patient at any time as well as to compare the current and the initial state of the patient. Visualization considerably simplifies the perception of the clinical picture both for the patient and for the doctor, thus making the treatment process itself also easier. Having all these data available, the doctor can see the necessity of prescribing additional tests and check-ups in order to make the final diagnosis.
№ Main partQ Palpation of the head Right Left
l M.temporalis ant.
2 M.temporalis med. ; ;
3 M.temporalis post. ;
4 M.masseter \ \
5 Ui M.masseter
6 v] Ü M.pterygoideus lateralis ; ;
7 Bpterygoideus lateralis 1 f
8 M. mylohyoideus ; ;
9 M.digastricus MM
10 M.sterno-cleido-mastoideus 1 I
11 M. trapezius
12 M.occipitalis ; ;
13 PAIN
14 O u Forward position of mandibular head
15 Back position of mandibular head
16 £ PAIN
17 o 'u) Lig. temporomandibulare
18 H : 3 Deviation
19 L'J Defllron
20 Rotation
21 u C Translation
22 (J Right turning
23 Left turning
24 Crepitation
25 Teeth irnprints^n the tongue
* Tp - trigger point; Sg - segmentation; Gt - hypertonus; Gtr - hypertrophy.
FUNCTIAL CONTACTS (with the help of copy paper or occlusiogram)
®
NAME, SURNAME
AGE
DATE
Diagnostic card of craniomandibular patient
№ MAIN PART© Describe the intensive from 1 to 5 v/x On right 1/5 On left 1/5
1 Headache
2 When mouth is opened
3 o c When mouth is closed
4 Pain when the jaw is shifted to the right
5 Q. c o Pain when the jaw is shifted to the left
6 O -t-» re When closing teeth
7 O T3 re Pain in the joint
8 re N Earache
9 re u Neckache
10 o Pain behind the head
11 Backache
12 00 c 1c Crunch in the joint when opening the mouth
13 c u Crunch in the joint when closing the mouth
14 Tinnitus when opening the mouth
15 LO Tinnitus when closing the mouth
16 LU Feeling of fluid in the ears (stuffiness in ear)
17 Decreased audibility (feeling)
Localization of pain
ffHfï
i \
n Ö'W)1
w W 1; ;
J~L J C \ M 1 cÖÖo
Irradiation of pain n
» L
~,\¡.rr—-^K
to
jf\i ! i i / mk
Numbness on the face
□
№ MAIN PART© V/X Answer/Descriptio n *
1 Have you ever felt pain in the muscles of the facing the morning or evening?
2 Have you felt lower jaw contraction in the morning after awakening?
3 Have you noticed when you closing teeth you are trying to find a comfortable position?
4 Have you oryour closest people noticed night gnashing of teeth?
5 Have you or your closest people noticed your snore? (troubled sleep, frequent awakening, night
6 Do you feel involuntary closing teeth?
7 Have you ever had trauma, facial surgery, or general anesthesia (intubation)?
8 Have your wisdom tooth been removed? How long ago?
9 Have you been treated by an orthodont? How long ago?
10 Have you noticed a feeling of having a lump in the throat or difficulties with pronunciation?
11 Do you think your state of health is serious?
12 How often you feel stressed?
13 How do you rate your emotional state recently? Anxietym; Fearm; Anger □; Irritation □; Calmness □.
14 Do you feel a need for treatment?
Signature of consultant physician
Signature of patient
