Here’s the scenario:
If a patient presents with a dull ache in the joint before load testing and the three stages of load testing don't cause any additional discomfort, but there is still that same dull ache present throughout. Should you proceed to occlusal treatment?
If you answered yes, I caution you.
We solve so many problems with occlusal treatment that we start thinking that every problem we see is an occlusal problem. If you have any pain in the masticatory system that you cannot precisely determine what it is, there's a simple rule: find out what it is. In other words, make a diagnosis.
If I could overly simplify it, you start at the outside and work in. I have to tell you that in my many years of practice I received a lot of referred patients that dentists had been working on with no results. They would say, "Well, I just can't figure it out. The occlusion isn't helping," and then I would see the patient and find a malignant tumor in the masticatory system.
I had three patients exactly as you described in this scenario that had malignant tumors of the masseter muscle. It's a very rare thing, but I've had a couple of patients with malignant tumors of the parotid gland that were being treated with occlusion. We've had numbers of patients - I couldn't even count them - that have had serious benign tumors, but there's still a major problem with osteochondrosis of their condyle. They had to have major surgery because it was growing and growing while the dentist was trying to adjust the bite or work with occlusal splints.
You want to find out what the dull ache is and if a patient can put their finger on the spot where the pain is coming from, just start on the outside and work in. They might have a huge cyst in the ramus. They might have an abscess tooth. It's amazing, but the number one thing that gets missed in all facial pain is an abscessed tooth because it will come along with occlusal muscle pain. Dentists fix the occlusion and they think, "Well, I just need to keep working on that one with more occlusal splints and all," and they forget to look past the occlusion.
We're physicians of the masticatory system and that involves a lot of careful analysis on our patients.
What we teach, and what you will learn if you read the book, attend our courses and study some, is that as masticatory system physicians it's our responsibility to find out with any pain in our system, is the masticatory system or some aspect of a masticatory system disorder responsible for all of the pain, some of the pain, or none of the pain? And very often, it's some of the pain, and there are layers of pain.
We can see, very commonly, cervical problems that are reflected into the system. We don't treat the cervical problem, but there are layers of pain, and when you have a cervical problem in combination with a masticatory system problem, both of them enhance each other. Same with ear pain. You can have ear pain that enhances the masticatory system pain, and you miss the ear pain. But we have the capability to know when we have a masticatory system disorder, and we can absolutely rule it in or out.
If we can rule it out - by testing and checking the condyles and verifying if they're stable and healthy and that we don't have an occlusal muscle problem, and the pain is still there - then we refer that patient to the appropriate specialist.
To practice predictable dentistry, it is crucial that we make a diagnosis first.