11. Diagnosis in FPD Flashcards
How do you modify treatment for an epileptic? (2)
- Metal occlusal surfaces
- Short appointment
What happens for patients with Xerostomy?
Higher caries incidence
What happens with patients with diabetes?
Higher incidence of periodontal disease
What happens with patients with HIV?
Higher incidence of periodontal disease
What happens to patients with hyadantoin treatment?
Gingival hyperplasia
What are the pathologies that might make us modify treatment?
- Epilepsy
- allergies
- xerostomy
- diabetes
- HIV
- hydantoin
- sjogren syndrome
What is the helkimo test? (4)
Sum of points evaluating:
- movement limitation
- pain during movement
- muscular pain
- TMJ pain and the function
What is does a 0 helkimo test mean?
No TMDs
What is does a 1 helkimo test mean?
- Mild TMD
- 1-4 points
What is does a 2 helkimo test mean?
- moderate TMD
- 5-9 points
What is does a 3 helkimo test mean?
- severe TMD
- 10-25 points
Where is muscular palpation done? (3)
- into the bulk of the muscle
- against a hard plane (some bone nearby)
- at the insertion of the ligament
How do you check the pain threshold of the patient? (2)
- palpate mastoid process
- or vertex
How do you palpate the temporal muscle? (2)
- along muscular fibers
- from front to back
How to you palpate the tendon of the temporal muscle ? (2)
- with index finger over the ramus of the mandible
- towards coronoid process
How do you palpate the deep part of the masseter muscle?
15mm in front of the tragus, below the zygomatic arch
How do you palpate the superficial part of the masseter muscle? (3)
- Over the ramus ofthe mandible.
- From back to front.
- Craniocaudally.
How do you palpate the masseter intraorally?
one finger intraorally and another extraorally
What does bilateral pain of the masseter muscle mean?
Indicates clenching
What does unilateral pain of the masseter muscle mean?
May be due to an interference
What is the first muscle to usually be affected my TMDs? (2)
Lateral pterygoid
- can sometimes pull from the disc displacing it
How do you palpate the lateral pterygoid?
Little finger at the bottom of the upper vestibule behind retromolar process
How do you palpate the medial pterygoid?
- difficult
- only lower insertion, below the lower border of the angle of the mandible
How do you palpate the SCM?
Along the muscle
How do you palpate the posterior belly of digastric muscle?
- Palpation with little finger ebtween posterior corder of the ramus of the mandible and the SCM
- Head of patient to the front and downwards
Muscular pain occurs either at: (2)
- maximal stretching of the muscle
- maximal contraction
Apart from painful muscular points, you should assess these in a functional examination:
- Muscle hypertrophy.
- Face asymmetries.
- Muscle hypertonicity.
- Spasm.
Functional limitation of muscular movement: Soft end feel? (3)
- Muscles allow 2 mm stretching.
- The opening can be increased when applying some force
over the jaw. - Painful.
Functional limitation of muscular movement: Hard end feel? (3)
- Articular problem, not muscular.
- The mandible can’t be opened more, even when a gentle
force is applied. - The opening can not be forced.
Functional limitation of muscular movement: Maximum mouth opening? (5)
- Less than 40 mm interincisal opening.
- Due to pain and spasm of elevatormuscles.
- Protrusion and lateralities.
◦ Usually not limited (8mm) due to muscles.
◦ Unless lower lateral pterygoid is highly affected.
Functional examination: opening-closing path? (3)
- more than 22mm defelction
- muscular or articular problem
Functional examination: opening-closing path muscular problem?
Variable deviated path
Functional examination: opening-closing path articulation problem?
always the same path
What is the more frequent pathology in joint examination?
- Muscular pathology (more frequent)
- articular pathology
What is the most frequent articular pathology when doing joint examination?
Intracapsular pathology
Where does articular pain come from?
Usually not the articular surface, but from the surrounding tissues
How do you externally palpate articular pain
- palpation of the lateral part of the condyle
- index and middle fingers in front of the tragus
What are the two kinds of articular pain palpation? (2)
- External (laterally)
- Internal (posteriorly)
When externally palpatating articularly, what does pain indicate?
Capsulitis or synovitis
How do you internally palpate for articular pain?
Little finger into external auditory canal pushing forward
If there is pain when internally palpating for articular pain, this indicates… (2)
- retrodiscitis (very common)
- posteriot capsulitis or synovitis
Articular sounds: what is a click?
Single explosive sound
Articular sounds: what is a crepitus??
Continous grating noise
How can you hear articular sounds?
- With the bell of the phonendoscope
- while preforming opening-closing or eccentric movements
- lateral palpation
What can cause click articular sounds?
- disc-condyle incoordination
- during disc recapturing
What does it mean if there is a click articularly during opening? (2)
◦ Indicate anterior functional displacement of the
disc.
◦ Milder stage the nearer the MI point.
What does it mean if there is a click articularly during opening-closing? (4)
◦ Reciprocal click (or clicking)
◦ Indicate disc dislocation with reduction
◦ Early on opening, late on closing usually
◦ More advanced stage
A click sound during mediotrusion indicates…
medial disc dislocation
What are the causes of crepitus sounds? (3)
- Due to wear of the articular surfaces.
- TMJ Osteoarthrosis.
- Rx to see this: Schüller’s transcranial radiography.
What is the problem when there is a maximum mouth opening of less than 40mm with hard end feel ? (2)
- articular problem
- probably an anterior disc dislocation without reduction
What is the problem when there is a mediotrusion of less than 8mm?
Probably an anterior disc dislocation without reduction
What is the problem when there is lateral deflection of the mandible during protrusion?
deflection towards the affeted side (DDwoR)
What is considered a pathological deflection during opening-closing ?
more than 2mm
If there is a reduction during opening-closing: (2)
- The deflection ends again at the midline.
- Deflection during the opening path
If there isn’t a reduction during opening-closing:
- The deflection doesn’t get back to the midline
- disc displacement without reduction -> affected condyle only rotates-> deflection to the affected side
What is considered urgent in preprosthetic treatments?
Pain or infection
What pathologies require urgent treatment? (4)
- Acute pulp diseases (pulpitis).
- Periodontal abscesses.
- Tooth fractures.
- Acute TMDs (trismus).
What malocclusions require immediate treatment: (2)
- Fremitus.
- Any occlusal contact clearly harmful to the patient.
What do we do if an anterior tooth needs to be extracted?
- Provisional immediate denture (Fixed or removable) prepared in advance
Then:
- removable denture
- maryland bridge
- provisional bridge
Third molars and attached gingiva?
- Hardly ever have attached gingiva at buccal and lingual surfaces
Should we extract third molars for bridges? (3)
Yes unless:
- They’re in perfect condition
- risk to inferior alveolar nerve
When extracting third molars, possible extrusion of the antagonist can cause: (2)
- prematurities
- inadequate contact point: food impactation
*therefore extract antagonist too
How long should you wait after extraction?
6m-1year
What happens if you dont wait the recommended time after extraction for prosthetic treatment? (3)
- bone resorption can still happen
- gingival level migration
- separation between pontic and gingiva
What happens if you wait more than a year after extraction for prosthetic treatment?
Tooth migrations
What are the stages of periodontal treatment? (3)
- initial treatment
- surgical treatment (if needed)
- maintenance
What occurs in the initial periodontal treatment? (3)
- prophylaxis
- scaling and root planning
- correction of overcontoured margins of restorations and other iatrogenic irritants
What happens 2 months after scaling and root planning?
Reevaluation and decision:
- surgical treatment
- more SRP
- prosthetic treatment
What happens during the 2 months after scaling and root planning? (3)
- Evaluation of the commitment of the patient with it’s oral health.
- Stabilization of the gingival tissues
- Very important for any prosthetic treatment to
succeed.
How should you check occlusal equilibration?
- mount cast in CR
- eliminate contacts on the casts
When should we not do occlusal equilibration? (2)
- more than 4 contacts
- eliminating one contact can lead to another appearing
When should you do occlusal equilibration? (5)
- Only for occlusal contacts clearly harmful to
the patient. - Fremitus.
- Extrusions that might interfere with the
denture. - Unevenness of the occlusal plane.
- Lack of occlusal stability
How long after a fistula/abscess treatment should you wait for prothetic treatment?
6 months
*be sure of the remission of the pathology
When should you do an endo therapy of vital teeth? (4)
- When cast post-and-core is needed (retention).
- Extrusions.
- Great tooth inclinations.
How long after an endo therapy of a vital tooth should you wait before prothetic treatment?
1 month
How long after an apicectomy should you wait before prothetic treatment?
6 months for full healing
What is the disadvantage of an apicectomy? (3)
◦ Low crown-to-root ratio.
◦ Unaesthetic scar.
◦ Sometimes increases tooth
mobility.
Should you extrude or intrude teeth to increase the ferrule effect?
extrude
How long after periodontal surgery can you do prothetic treatment?
• Only gingiva has been
touched: 1 to 3 month
• Gingiva and bone: 6month
How long should you wait after any surgery to do prosthetic treatment?
2-3 months
How do you treat TMDs? (4)
- physiotherapy
- pharmacotherapy
- psychological support
- Occlusal splint
What physiotherapy should be done to treat TMDs?
- massage
- therapeutic exercises
- TENs
- infrared light
How do massages help TMDs?
Increases the heat and helps
eliminating toxins during the contraction
How do therapeutic exercise help TMDs?
To help recover the
function; limiting the movements, opening
and closing
How do TENs help TMDs?
Transcutaneous electrical nerve stimulation, to reduce the pain and stimulate
the tone of the muscles
How do infrared light help TMDs?
Creates a heat that improves
the blood-flow, the oxygenation and relaxes
the muscles.
Whats the purpose of pharmacotherapy in treatment of TMDs (3)
- To reduce the psychological tension.
- To relax the muscles.
- Allow maneuvers needed during the treatment.
Types of pharamcotherapy for TMD?
Cold/heat
• Muscle relaxant, robaxisal®, myolastan ®.
• Sedative and tranquilizer, can help the doctor reduce
the pain, benzodiazepines.
• Analgesic, not very useful to relieve acute pain,
paracetamol.
• Anti-inflammatories
• Vasoactive drugs: for vascular migrains
• Infiltrations in the affected areas
How does heat impact TMDs? (3)
- can creates changes over the neuromuscular
system - increase of the blood-flow and the capillary permeability.
- When muscular tension, pain and rigidity of the joints
How does cold impact TMDs? (5)
- anaesthetic effect, reduces spasms and the bloodflow
- reducing the local inflammatory response
- oedema,
- haemorrhage.
- When jaw movements are limited associated to active
therapy
Psychological support for TMD (3)
• Stress and Anxiety are a cause and consequence of
TMDs.
• Psychologist.
• Psychiatrist.
What does occlusal splinting for TMD achieve?
Alters mandibular position and contact pattern of teeth
How occlusal splinting for TMD work? (3)
• It hasn’t been proved what makes them work.
• It has been stated that it’s because it resets
neuromuscular patterns.
• Synonymous of occlusal device.
What are the indications of occlusal splinting for TMD? (7)
- Relaxes the muscles.
- Helps reducing the pain.
- Allow to handle the patient
during the treatment. - Treatment for TMD`s.
- Occlusal stabilization.
- To prevent the occlusal
trauma. - Reduce tooth wear.
What is occlusal splinting for TMD effective at and not effective at?
- Very effective at reducing muscular pain.
* Poorly effective to reduce joint sounds.
Whats the objective of occlusal splinting for TMD? (5)
- Relax muscles of the stomatognathic system.
- Provide orthopedic stability to TMJs.
- Lower grinding/parafunctional activity.
- Protect periodontium from occlusal trauma.
- Prevent wear of the dentition.
What is the procedure of occlsal splinting for TMD? (2)
- Occlusal record at final VD in CR position
- The purpose is to take the condyle-disc-fossa to
an optimum position
What is needed before occlusal splinting for TMD
Physiotherapy and pharmacology to be able to treat the patient
How do you occlusally splint when its impossible to record CR? (2)
- Approximate CR.
- Posterior adjustments to the splint or new splint.
Hwo do you manufacture occlusal splints? (3)
Heat curing acrylic resin
- good mechanical properties
- allows adjustments
What splint do you need for night-time bruxism for TMD?
Upper splint
What splint do you use for day-time bruxism for TMD?
Lower splint
Design of the occlusal splint for TMD? (3)
- Retention: survey line.
- Avoid contact with periodontium (plaque
gathering) . - Flat occlusal surface
What occlusal scheme do you use for occlusal splint TMD?
- Mutually protected articulation
- soft canine and anterior guidance
How should the contacts be in a TMD occlusal splint? (3)
- even contacts
- no tooth without occlusal contact (prevents extrusions)
- minimum possible VD (not making the splint weak) - to prevent myotatic reflex
What is the time of use for an occlusal splint for TMDs? (2)
- depends on the patient
- bruxist patients: forever
Do occlusal splints have MI at CR? (2)
- Rarely achieved the first time:
- Adjustments to the splint.
