If a patient is in pain before loading, is the patient in CR?

This video is an excerpt from the April 2015 Dawson Faculty Office Hours with Drs. Leonard Hess and Rajeev Upadya. To watch the full office hours and to sign up for future office hours, visit the Videos and Webinars page. 

Question: If a patient is having pain when manipulated into Centric Relation (CR) before loading even begins are you suspecting that the patient is not completely in CR, or maybe intracapsular disorder?

Raj:

Initially if I’m not in CR at all and the patient is experiencing discomfort, first of all I stop for a second and reassess. I take a look at my positioning – making sure I’m approaching the patient properly and doing bimanual manipulation properly.

If they experience pain again as I try again, I ask very specifically where they are feeling the tension or tenderness. If they are pointing inside the actual joint space there, I stop automatically and start suspecting we have an intracapsular disorder. If they are pointing and saying it feels like it’s pulling or has tension over here and they’re pointing more toward the front to the deep Masseter or anterior to the joint, I’m more suspecting its an Occluso-muscle issue and not necessarily an issue with the intracapsular.

Lenny:

The main thing to remember when doing the Centric Relation load test is to ask the patient, “Are you feeling any sign of tension or tenderness?” Tenderness of course, would be related to pain as well.

When we have a patient that is feeling pain and is identifying a pain response we always have to be cautious and realize we may be experiencing an intracapsular disorder or a medial pole placement. Now the condyle is seating and loading onto Retrodiskal tissue, which we know is where the innervation is within the joint system itself. We have to be very careful.

That’s why when we do a Centric Relation load test, we always start with the lightest loading first and if we get a positive response (of pain) for that patient, we stop. There’s no sense in loading a joint that is painful or tender with any more pressure if we are already getting a positive load response (for pain).

Getting a positive load response leads us down the path of trying to figure out why it’s positive – it’s either joint or muscle. To answer that question – if you’re close to CR or in CR and you’re very lightly loading and the patient is experiencing pain you have to be weary of having an intracapsular disorder or medial pole issue.

Question: My most recent patient kept pointing at the joint when I put him in CR or what felt like CR. 

Lenny:

One of the things we have to remember is that it is our job to delineate between intracapsular and muscular problems. If you think about most patients that are experiencing discomfort – I see it all the time with patients coming into my practice – they think they’re having a TMJ problem. You ask them to point to where it’s hurting. They often aren’t pointing to the joint, they’re pointing in front of the joint. And what’s in front of the joint is the Lateral Pterygoid.

Remember when the Lateral Pterygoid is not in CR and the muscle can never release, both the superior and inferior belly stay in a constant state of action or spasm. We all know how bad a charlie horse can hurt in our leg; it is a very painful thing. Even though that Lateral Pterygoid is a very small little muscle, when it gets a little charlie horse in it, it can be very painful and sore. It’s very close to being in that joint space and many patients don’t know anatomically what’s going on. They just know it hurts right in front of their ear.

Most of the time, many patients who think they are having a joint problem, when we take them through the complete examination and paint that clinical diagnostic picture (we deprogram them, we put them on the Doppler), typically we find it’s a Lateral Pterygoid that is spasming and can’t release.

Remember when you have a Centric relation hit and slide, your muscles have proprioceptive memory to them. They know where they have to keep that mandible position so that if you bite together really quickly, your teeth line up. When you try to seat someone into Centric Relation, the Lateral Pterygoid knows the joint is not supposed to go there because if you go there the teeth don’t line up right. Instead it’s always trying to pull that condyle forward just out of the glenoid fossa just down that eminence a little bit so that maximum intercuspation can happen quickly and efficiently.

You’re going to see that situation often and that’s why it’s so important to stay true to our process of the complete examination and do every step of it. You’ll often find your answer quickly from it.

Question: Wouldn’t muscle palpation of the individual muscles be able to help distinguish the location? 

Lenny:

Absolutely. Muscle palpation is a part of our complete exam. The only problem is that we can’t palpate the Lateral Pterygoid. We can try to instigate it by having the patient push their chin forward and we kind of push on it, but that is a very unreliable diagnostic tool.

If we are trying to delineate between intracapsular or muscular issues, and we think the problem is the Lateral Pterygoid and the Doppler is telling us the medial pole is in tact (we aren’t hearing anything), when we put them in a lucia jig or any kind of anterior deprogramming device, within a very short period of time, we are going to have our definitive answer. When that Lateral Pterygoid shuts down, that condyle goes up into the glenoid fossa it’s either going to hurt or it’s not.

Muscle palpation is a critical portion of what we do and it absolutely helps us distinguish what it is we are doing. The Lateral Ptyergoid can fool us, though, because we can’t palpate it.