I was recently talking with a student who described a patient who could not load the joint comfortably. Additionally, the patient had severe wear, an uneven occlusal plane, broken crowns, and despite deprogramming with a cotton roll, he would feel quite a bit of tenderness when the TMJs were load tested.
This is a case where sending your patient home with a deprogramming device might be the wrong thing to do. If this is an intracapsular disorder, using a deprogramming device might actually make the patient worse.
Some of your patients are going to have intracapsular disorders that need diagnosis.
As you go through our core curriculum, you will learn how to diagnose these disorders with great accuracy, but if you are not there yet, don’t just ignore the possibility that your patient may have an intracapsular disorder.
How do you diagnose an intracapsular disorder?
If you are not sure if your patient has an occluso-muscle disorder or an intracapsular disorder, try the following:
- Take about a four-inch cotton roll and lay it across the bicuspid so that the back teeth can't touch
- Ask the patient to lie there and relax for 15 or 20 minutes.
- Come back and try loading the joint again.
If the TMJ still cannot accept loading with complete comfort, there is a very good probability you are dealing with an intracapsular disorder. Usually within 15 or 20 minutes, the muscles are going to release if you're not letting the back teeth touch. This is a real simple thing to do and it's diagnostic.
Always keep in mind that muscle problems get better with the deprogrammers and joint problems will usually get worse. So, if you can't load the joint and the cotton rolls don't help (and maybe even make it worse), you must find out why. Get imaging of the patient’s joints. That way, you can see what's going on without guessing. Then, as you go through the curriculum you will learn what to do with those patients.
Don't be discouraged if you aren’t prepared to treat that patient yet. Just consider yourself fortunate that you are able to recognize the patient’s problem. When you diagnose that intracapsular disorder, you are probably going to be the first dentist that's actually told the patient what's going on with them.
About 90% of the time, what appears to be a TMJ problem is actually an occluso-muscle disorder. Probably less than 10% of the time, you will come across an intracapsular structural problem. The good news is if you have a solid understanding of occlusion, you should be able to treat 90% of your patients right now.
How do you proceed after diagnosing an intracapsular disorder?
Even when you have a diagnosis, this is not the patient you want to start equilibrating or changing their occlusion. Don't do that until you can verify centric relation.
Always follow this simple rule: if you cannot comfortably the load the TMJs, you must find out why before you make any changes to the occlusion.
If you have a patient with an intracapsular disorder and you need some help with the patient, call The Dawson Academy and we'll align you with a dentist that has had some experience with treating these disorders. You can learn a tremendous amount by working with a doctor that knows how to handle them.
You'll find that helping these patients really is not tremendously complicated, and they often turn into wonderful restorative cases once they're stable.
I know you are going to be amazed at the number of your general practice patients who come to you with oral-facial pain problems that have never even been recognized as having a dental related cause. Knowing how to recognize such problems really will set you apart from the usual and customary dental practice.