Color Atlas of Dental Medicine

Editors: Klaus H. Rateitschak and Herbert F. Wolf
TMJ Disorders and Orofacial Pain

The Role of Dentistry in a
Multidisciplinary Diagnostic Approach
Axel Bumann and Ulrich Lotzmann
In Collaboration with James Mah
Translated by Richard
Jacobi, D.D.S. Belton, TX,
U.S.A.
1304 Illustrations
Thieme
Stuttgart • New York
iv
Authors' Addresses
Dr. Axel Bumann, D.D.S., Ph. D.
Clinical Assistant Professor
Dept. of Craniofacial Sciences and
Therapy
University of Southern California
925 W 34 St, Suite 312
Los Angeles, CA 90089-0641
USA

MEOCLINIC
International Private Clinic
Friedrichstr. 71,10117 Berlin
Germany Prof.Dr.A.Bumann@kfo-
berlin.de


Library of Congress Cataloging-in-
Publication Data is available from the
publisher.
Illustrations by
Design Studio Cornford, Reinheim
Joachim Hormann, Stuttgart
Cover design by Martina Berge, Erbach
This book, including all parts thereof, is
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sent, is illegal and liable to prosecution.
This applies in particular to photostat
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or duplication of any kind, translating,
preparation of microfilms, and electronic
data processing and storage.
This book is an authorized translation
of the German edition published and
copyrighted 2000 by Georg Thieme
Verlag, Stuttgart, Germany.
Title of the German edition:
Funktionsdiagnostik und
Therapieprinzipien
© 2002 Georg Thieme Verlag,
RiidigerstraBe 14,
D-70469 Stuttgart, Germany


changing science undergoing continual
development. Research and clinical expe-
rience are continually expanding our
knowledge, in particular our knowledge
of proper treatment and drug therapy.
Insofar as this book mentions any dosage
or application, readers may rest assured
that the authors, editors, and publishers
have made every effort to ensure that
such references are in accordance with
the state of knowledge at the time of pro-
duction of the book.
Nevertheless this does not involve,
imply, or express any guarantee or respon-
sibility on the part of the publishers in
respect of any dosage instructions and
forms of application stated in the book.
Every user is requested to examine care-
fully the manufacturers' leaflets accom-
panying each drug and to check, if neces-
sary in consultation with a physician or
specialist, whether the dosage schedules
mentioned therein or the contraindica-
tions stated by the manufacturers differ
from the statements made in the present
book. Such examination is particularly
important with drugs that are either
rarely used or have been newly released
on the market. Every dosage schedule or
every form of application used is entirely

to my brothers and sisters and my godchildren,
with great love and gratitude
To the crew of Apollo XII:
Charles "Pete" Conrad (1930-1999), in memory;
Richard Gordon and Alan Bean,
in admiration and friendship
Ulrich Lotzmann

vii
Foreword
The title of this opus presents the philosophy of the authors,
namely that dentistry is only one part of a multi-faceted
service for temporomandibular dysfunction. Dentists would
argue that their service is the most important. Indeed, TMJ
problems are largely within the province of dental care;
however, like a horse with blinders, therapy has concen-
trated on the mechanical aspects, largely ignoring the phys-
iological and psychological areas that are so important, if we
are to render optimal service. In other words, dentistry itself
must broaden its diagnostic and therapeutic horizons and
de-emphasize the tooth-oriented vision and mechanical
procedures. The authors clearly state this in their preface -
based on their great clinical experience. If the reader is look-
ing for a fancy articulator that replicates the stomatognathic
system, he is in the wrong place.
Too many dentists have been led down the primrose path,
aided by TOT (tincture of time) as patients improve, regard-
less of the therapy employed. TMJ problems are largely
cyclic, and are often self-correcting via homeostasis, with
time and advancing age.

roles that the skeletal osseous parts, the condyle, the
glenoid fossa, the articular disk, the capsule, ligaments,
muscles and that too-often neglected retrodiskal pad
(bilaminar zone) play in the whole picture. Equally impor-
tant, as we assemble the diagnostic mosaic for treatment, is
the psychological role, the stress-strain-tension release
mechanisms that we resort to in our complex society today.
We must make sure, in our diagnostic exercise, that we
know which is cause and which is effect. Wear facets on
teeth may well be the result of nocturnal parafunctional
activity, i.e., bruxism. And even more important, and too
often neglected, is nocturnal clenching, which is also a man-
ifestation of the stress-strain release syndrome, especially
at night. Lars Christensen showed conclusively that as little
as 90 seconds of clenching can cause neuromuscular
response, i.e., pain and muscle splinting. Does the condyle
impinge on the retrodiskal pad, with it's network of nerves
and blood vessels, and the important role it plays in the
physiology of the temporomandibular joint? Here again,
important information is provided by the authors, based on
the landmark work of Rees, Zenker and DuBrul. Recent
research validates the important role that the bilaminar
zone or retrodiskal pad plays in TMJ physiology. Thilander
showed in 1961 that pain response in the temporomandibu-
VIII
lar joint can come from condylar impingement on this
neglected post-articular structure. Isberg showed graphi-
cally the damage possible by forced impingement on the
same tissues. Yet we have to be smart enough to know the
difference between cause and effect.

Depending on the diagnostic assessment and classification
described beforehand, the clinician may use a relaxation
splint, a stabilization splint, a decompression splint, a
repositioning splint, or a verticalization splint. Again,
diagnosis is the name of the game in their choice. Along
with supplemental use of muscle relaxants, heat, infrared
radiation, stress relief and counseling.
Profuse color illustrations make following the text easy and
enhance the understanding of the concepts. A recent scien-
tific study showed conclusively that color pictures are easier
to comprehend by the human brain. This color atlas is a
good example of this fact. Excellent production, for which
Thieme is noted, enhances the value of the book. Read,
enjoy and learn!
T.M. Graber, DMD, MSD, PhD, MD, DSc, ScD, Odont.Dr. FRCS.
Professor
IX
Foreword
The authors of this extraordinary atlas have given the dental
profession an extremely comprehensive and well-organized
treatise on the functional diagnosis and management of the
masticatory system. Historically, dental literature in the field
of occlusion has been primarily based on clinical observa-
tions, case reports and testimonials. This extremely well ref-
erenced atlas is a welcome addition to the momentum
within the dental profession to move the field forward to a
more evidenced-based discipline. The multidisciplinary
diagnostic approach presented in the atlas is well estab-
lished and supported by published data. Chapters include
up-to-date information and exquisite photography on the

extremely well organized, skillfully written, and beautifully
illustrated atlas. I especially appreciated their attempt to
provide the reader with, wherever possible, current and
complete references and, thus, add important evidenced-
based literature to the field. This treatise on functional dis-
turbances of the stomatognathic system should be required
reading for anyone interested in the diagnostic process and
treatment planning in dentistry in general. Additionally, the
detailed chapters describing the various diagnostic func-
tional techniques with accompanying exquisite illustrations
make this an outstanding comprehensive teaching atlas in
occlusion for students and clinicians.
Charles McNeill, D.D.S.
Professor of Clinical Dentistry & Director,
Center for Orofacial Pain
School of Dentistry, University of California, San Francisco
Foreword
Dr Bumann and Dr Lotzmann are two authors with an out-
standing amount of information and illustrations at their
disposal. Working together with Thieme, a publisher known
for its ability to communicate through the use of illustra-
tions, to produce this book has proven to be a perfect col-
laboration.
Imaging can play an important role in the diagnostic and
treatment processes associated with orthodontic, restora-
tive, and craniomandibular disorder patients, because find-
ing the correct diagnosis is crucial for the development of
the optimum treatment strategy as well as for the applica-
tion of the appropriate treatment. This book illustrates suc-
cessfully a range of complex anatomic conditions involving

exclusive domain of diagnostic imaging.
The authors have created a well-illustrated textbook, detail-
ing many of the biomechanical aspects of craniomandibular
disorders. The imaging portions alone would make this a
valuable reference text for all practitioners trying to under-
stand or diagnose patients with craniomandibular disor-
ders.
David C. Hatcher, DDS, MSc, MRCD (c)
Acting Associate Professor
Department of Oral and Maxillofacial Surgery
University of California San Francisco
San Francisco, CA
XI
Foreword
Craniomandibular disorders are a group of disorders that
have their origin in the musculoskeletal structures of the
masticatory system. They can present as complicated and
challenging problems. Almost all dentists encounter them
in their practices. In the early stages of the development of
this field of study the dental profession felt that these dis-
orders were primarily a dental problem and could most
often be resolved by dental procedures. As the study of
craniomandibular disorders evolved we began to appreciate
the complexity and multifactorial nature that makes these
disorders so difficult to manage. Some researchers even
suggested that these conditions are not a dental problem at
all. Many clinicians, however, recognize that there can be a
dental component with some craniomandibular disorders
and when this exists the dentists can offer a unique form of
management that is not provided by any other health pro-

further validated with scientific data.
In this atlas the authors introduce the term "manual func-
tional analysis" as a useful method of gaining additional
information regarding mandibular function. They have
developed these techniques to more precisely evaluate the
sources of pain and dysfunction in the craniomandibular
structures. Each technique is well illustrated using clinical
photographs, drawings and, in some instances, anatomical
specimens. Elaborate, well thought out, algorithms also help
the reader interpret the results of the mandibular function
analysis techniques. Although these techniques are not fully
documented, they are conservative, logical, and will likely
contribute to establishing the proper diagnosis. The authors
also provide a wide variety of methods, techniques and
instrumentations for the reader to consider.
This atlas provides an excellent overview of the many
aspects that must be considered when evaluating a patient
with a craniomandibular disorder. Appreciating the wealth
of information presented in this atlas will certainly assist
the dentist in gaining a more complete understanding of
craniomandibular disorders. It will also guide the practi-
tioner to the proper diagnosis. I am sure that the efforts of
Dr. Bumann and Dr. Lotzmann will not only improve the
skills of the dentists, but also improve the care of patients
suffering with craniomandibular disorders. My congratula-
tions to these authors for this fine work.
Jeffrey P Okeson, DMD
Professor and Director
Orofacial Pain Center
University of Kentucky College of Dentistry

therapist G. Groot Landeweer this knowledge was taken up
and developed further into a practical examination concept
during the late eighties. Because the clinical procedures dif-
fer from those of classic functional analysis, the term "man-
ual functional analysis" was introduced.
The objective of manual functional analysis is to test for
adaptation of soft-tissue structures and evidence of any
loading vectors that might be present. This is not possible
through instrumented methods alone. The so-called
"instrumented functional analysis" (such as occlusal analy-
sis on mounted casts or through axiography) is helpful nev-
ertheless for disclosing different etiological factors such as
malocclusion, bruxism, and dysfunction. Thus the clinical
and instrumented subdivisions of functional diagnostics
complement one another to create a meaningful whole.
In recent years the controversy over "occlusion versus psy-
che" as the primary etiological element has become more
heated and has led to polarization of opinions among teach-
ers. But in the view of most practitioners, this seems to be
of little significance. In an actual clinical case one is dealing
with an individualized search for causes, during which both
occlusal and psychological factors are considered.
Within the framework of a cause-oriented treatment of
functional disorders one must consider that while the elim-
ination of occlusal disturbances may represent a reduction
of potential etiological factors, it may not necessarily lead to
the elimination of symptoms. The reason for this is that
there can be other etiological factors that lie outside the
dentist's area of expertise.
Some readers may object to the fact that the chapters

Will) of the Harvard School of Dental Medicine, the Depart-
ment of Orthopedic Surgery (Chair: Dr. T. Einhorn) and the
Laboratory of Musculoskeletal Research (Director: Dr. L.C.
Gerstenfeld) of the Boston University School of Medicine
deserve our gratitude for their understanding support.
Graphic artist Adrian Cornford has demonstrated his great
skill in translating our sometimes vague sketches into
instructive illustrations. For this we are grateful.
Our thanks are due also to Prof. Sandra Winter-Buerke who,
in posing as our patient for the photographs demonstrating
the manual functional analysis procedures, submitted to a
veritable "lightning storm" of strobe flashes. She endured
the tedious photographic sessions with amazing patience.
Our thanks go also to the dentists Katja Kraft, Nicole Schaal,
and Sandra Dersch for their assistance with the photo-
graphic work in the chapters "Instrumented Analysis of Jaw
Movements" and "Mounting of Casts and Occlusal Analysis."
Furthermore, we would like to thank Dr. K. Wiemer and Mr.
A. Rathjen for their support in organizing the illustrations
and the intercontinental transmission of data.
We thank the dental technicians Mrs. N. Kirbudak, Mr. U.
Schmidt, and Mr. G. Bockler for the numerous laboratory
preparations.
We are grateful to the firms Elscint (General Electric), Girr-
bach, KaVo, and SAM for their support in the form of mate-
rials used in the preparation of this book.
We thank our students and seminar participants for their
critical comments and stimulating discussions. These
exchanges were a significant help in the didactic construc-
tion of this work.

62 Active Movements and Passive Jaw O
p
enin
g
with

Evaluation of the Endfeel
7 Primary Dental Evaluation 67 Differential Diagnosis of Restricted Movement
8 Findings in the Teeth and Mucous Membrane 68 Examination of the Joint Surfaces
10 Overview of Dental Examination Techniques 70 Manifestations of Joint Surface Changes

72 Conductin
g
the Clinical Joint Surface Tests

74 Examination of the Joint Capsule and Ligaments
11 Anatomy of the Masticatory System 78 Clinical Significance of Compressions in the Superior
12 Embryology of the Temporomandibular Joint and the Direction
Muscles of Mastication 84 Examination of the Muscles of Mastication
14 Development of the Upper and Lower Joint Spaces 89 Palpation of the Muscles of Mastication with Painful
16 Glenoid Fossa and Articular Protuberance Isometric Contractions
18 Mandibular Condyle 94 Areas of Pain Referred from the Muscles of Mastication
20 Positional Relationships of the Bony Structures 96 Length of the Suprahyoid Structures
22 Articular Dis
k
98 Investi
g
ation of Clickin
g
Sounds

41 Force Vectors of the Muscles of Mastication 123
—
Routine Protocol
42 Ton
g
ue Musculature 123
—
Protocol for Limitations of Movement
43 Muscle of Expression 123 —Primary and Secondary Diagnoses
44 Temporomandibular Joint and the Musculoskeletal System 124 Investigation of the Etiological Factors (Stressors)
45 Peri
p
heral and Central Control of Muscle Tonus 125 Neuromuscular De
p
ro
g
rammin
g

46 Physiology of the Jaw-Opening Movement 126 Mandibular and Condylar Positions
47 Physiology of the Jaw-Closing Movement 128 Static Occlusion
48 Ph
y
siolo
gy
of Movements in the Horizontal Plane 130 D
y
namic Occlusion
49 The Teeth and Periodontal Rece
p

Symptoms 183 Posterior Disk Displacement

184 Disk Dis
p
lacement durin
g
Excursive Movements

185 Re
g
ressive Ada
p
tation of Bon
y
Joint Structures
141 Imaging Procedures 186 Progressive Adaptation of Bony Joint Structures
142 Panoramic Radiographs 188 Evaluation of Adaptive Changes: MRI Versus CT
144 Portraying the Temporomandibular Joint with Panoramic 189 Avascular Necrosis Versus Osteoarthrosis

Radiograph Machines 190 Metric (Quantitative) MRI Analysis
146 Asymmetry Index 192 Examples of Bumann's MRI Analysis
147 Distortion Phenomena 194 MRI for Orthodontic Questions
148 Eccentric Transcranial Radiograph 195 Three-Dimensional Imaging with MRI Data

(Schuller Projection) 196 Dynamic MRI
149 Axial Cranial Radiograph According to Hirtz and 196 -Cine MRI

Conventional Tomography 197 -Movie MRI
150 Posterior-Anterior Cranial Radiograph according to 198 MR Microscopy and MR Spectroscopy


162 Reproduction of Anatomical Detail in MRI Arches
164 Visual (Qualitative) Evaluation of an MR Image 215 Jaw Relation Determination for Edentulous Patients
165 Classification of the Stages of Bony Changes 216 Mounting the Cast in the Correct Relationship to the
166 Disk Position in the Sagittal Plane Cranium and Temporomandibular Joints
167 Disk Position in the Frontal Plane 217 Attaching the Anatomical Transfer Bow
168 Misinterpretation of the Disk Position in the Sagittal Plane 220 Mounting the Maxillary Cast using the Anatomical
169 Morphology of the Pars Posterior Transfer Bow
170 Progressive Adaptation of the Bilaminar Zone 222 Mounting the Maxillary Cast using a Transfer Stand
171 Progressive Adaptation in T1 - and T2-Weighted MRI 223 Mounting the Maxillary Cast following Axiography
172 Disk Adhesions in MRI 226 Mountin
g
the Mandibular Cast
173 DiskHypermobility 228 Axiosplit System
174 Partial Disk Dis
p
lacemen
t
230 S
p
lit-Cast Control of the Cast Mountin
g

Table of Contents xvii

231 Chec
k
-Bite for Settin
g
the Articulator Joints 301 Princi
p


354 Index
269 Diagnoses and Classifications

270 Classification of Primary Joint Diseases
271 Classification of Secondary Joint Diseases
272 Hyperplasia, Hypoplasia, and Aplasia of the Condylar

Proces
s

273 Hyperplasia of the Coronoid Process
274 Congenital Malformations and Syndromes

275 Acute Arthritis
276 Rheumatoid Arthritis
277 Juvenile Chronic Arthritis
278 Free Bodies within the Joints
279 Styloid or Eagle Syndrome
280 Fractures of the Neck and Head of the Cond
y
le
281 Disk Displacement with Condylar Neck Fractures

282 Fibrosis and Bony Ankylosis
283 Tumors in the Temporomandibular Joint Region
284 Joint Disorders—Articular Surfaces
286 Joint Disorders—Articular Disk
287 Joint Disorders—Bilaminar Zone and Joint Capsule
295 Joint Disorders—Ligaments

Changes In the
occlusion
\
7
Altered
neuromuscular
programming
i
t

Changes In
Intrinsic and
extrinsic factors

Changes in
tooth position
Abrasion
Periodontal lesions
Dyskinesias
Changes in muscle tonus
Disturbances of
coordination
Lesions in the joint
surfaces
Capsulitis
Capsule constriction
Muscle shortening
Myofascial pain
Changes in body
posture

• adaptation as a reaction of the connective tissues;
• compensation as a muscular response to an influence
(Hinton and Carlson 1997).
Influences on the one hand and the capacity for progressive
adaptation on the other may achieve a physiologic state of
equilibrium. If, however, the sum of harmful influences dur-
ing a given period of time exceeds an individually variable
threshold, or if the adaptability of a system becomes gener-
ally diminished, the system will fall out of equilibrium. This
condition has been referred to as decompensation or regres-
sive adaptation (Moffet et al. 1964) and is accompanied by
more or less severe clinical symptoms. Regressive adapta-
tion of bone can be seen on radiographs (Bates et al. 1993),
and in soft tissues it is expressed as pain.
Because the adaptability of a system is primarily a genetic
factor and decreases with increasing age, the most effective
therapeutic measures are those aimed at the reduction of
the harmful influences.

2 Fundamentals of the etiology
of symptoms in the masticatory
system
Every biological system is subjected
to harmful influences of varying
severity. The ones listed here repre-
sent only a selection of those which
the dentist can demonstrate simply
and repeatedly. These influences
are assimilated by the system
through progressive adaptation


Regressive adaptation
and/or
decompensation
(subjective complaints)
Physiological Symptoms
structures
J

r3 Equilibrium between
influences and adaptation/
compensation
A healthy biological system can be
compared with a balanced set of
scales. The harmful influences on
one side are countered by the indi-
vidual's capacity for adaptation and
compensation. The adaptive and
compensatory mechanisms are ge-
netically determined and therefore
remain relatively constant, except
for a gradual decline with age. For
this reason, the equilibrium can
only be disturbed by change on the

• "Yellow" group: These patients have compensated func
tional disturbances and no history of problems. However,
symptoms can be repeatedly provoked by specific manip
ulation techniques.
• "Red" group: Patients with complaints whose symptoms
can be repeatedly provoked through specific examination
methods suffer from a decompensated or regressively
adapted functional disturbance.
In young patients, adaptation is based upon growth, model-
ing, and remodeling (Hinton and Carlson 1997). Modeling (=
progressive adaptation) is the shaping of tissues by apposi-
tion and results in a net increase of mass. Remodeling (=
regressive adaptation) is usually accompanied by a net
decrease of mass. In adults adaptation depends primarily
upon remodeling processes (de Bont et al. 1992). Physiological
structures
or
progressive
adaptation

Dental treatment, including

functional prophylactic measures


be carried out before any dental
restorative or orthodontic treat-
ment is initiated. The patient's
most urgent needs are determined
by which group of the patient pop-
ulation he/she is classified under.
For patients with complaints (red
group) a functional analysis should
be performed to arrive at a specific
diagnosis and to determine whether
or not treatment is indicated and
possible, and if so whether it should
be cause-related or symptomatic.
All other patients (green and yellow
groups) have no history of com-
plaints. If during a specific function-
al analysis with passive manual
examination techniques, compen-
sated symptoms can be repeatedly
provoked in an otherwise symp-
tom-free patient, the patient is
classified in the yellow (caution!)
group. Identification of these "yel-
low" patients is extremely impor-
tant because of the therapeutic and
legal implications. They make up
between 10% and 30% of the pa-
tients in an orthodontic practice.
Patients with compensated func-
tional disturbances are also of spe-

in the loaded structures and adaptation of the surrounding
structures. As a rule, the former are desirable and require no
treatment, whereas adaptations in the surrounding struc-
tures usually result in an increase of the load and restriction
of movement. Adaptations of surrounding structures are
always oriented in the direction of the loading vector and
therefore impede treatment. Within the framework of an
interdisciplinary treatment, it is the duty of the physical ther-
apist to eliminate any adaptive conditions in the surrounding
structures through manual therapy and measures to increase
mobility. Without a permanent modification of habitual
functional patterns, physical therapy will not be successful.

5 Schematic representation of
the treatment-directed examina-
tion sequence
To establish a function-based, prob-
lem-oriented treatment plan, it is
first absolutely necessary to gather
specific information in a rigidly de-
fined sequence. Our current con-
cept has been tested and validated
by more than 10 years of clinical ex-
perience. The three elements at its
core are the reproducible determi-
nations of destruction (= loading
vector), structural compensations
(= adaptations) and etiological fac-
tors (= influences). The first two el-
ements require the examination


Possible interdisciplinary
diagnostics

Treatment plan

Patient's complaints and
expectations Symptoms,
with primary symptom
General health history

Bone structure
Tooth structure
Periodontium
Soft tissues
Joint surfaces Articular
disk joint capsule
Muscles of mastication

Static and dynamic occlusion,
Parafunctional activities
Dysfunctional movements
Trauma

Tooth structure Periodontium
Malfunction of soft-tissue parts
Mandibular coordination
Muscle tone Jength, and
strength Capsule length
Disk position

Dental primary diagnosis
Direction of the destructive loading
(loading vector) • Manual functional
analysis • Imaging procedures

2* Evaluation of structural
adaptation
"Are there any impediments to treatment?"
Direction of the impediment (restriction
vector): Evaluation of innervation* muscle tone,
muscle strength, muscle length, capsule
mobility, nonreducing disk displacement

3. Search for possible etiological factors
"Why does the patient have this symptom?"
Direction of potential influences
(influence vectors):
? Patient history and inspection
? Clinical analysis of the occlusion
? Instrumented analysis of function
6 Evaluation of the destruction
The extent of intraoral destruction
is determined by the traditional
dental primary diagnostic meth-
ods. Damage to the individual
structures of the temporomandibu-
lar joint and the muscles of masti-
cation can be detected only
through manual functional analy-
sis. In some cases additional imag-

tion will not be helped by modifica-
tions of the occlusion.
Left: Example showing use of the
Mandibular Position Indicator to
help diagnose a static occlusal vec-
tor (see p. 128).

Introduction
The Role of Dentistry in Craniofacial Pain
Polarizing discussions during the past 10 years have made
the role of the dentist in diagnosing and treating pain in the
head and neck region increasingly obscure rather than more
clear. In the academic debate concerning the etiology—pre-
dominantly psychological factors versus predominantly
occlusal factors-the practitioner facing the problem of
treating a patient has been largely ignored. The argument of
multicausal genesis was previously taken as an excuse to
regard the multiple causes as an inseparable bundle rather
than to dispel at least a certain amount of confusion by
specifically testing the individual factors.
It is our opinion that every patient with head and neck pain
should be seen by a dentist in order to clarify the following
questions:
• Do the symptoms arise from a structure in the masticatory
system (presence of a loading vector)?
• Is the loading vector related to the occlusion?
• Can the occlusion-related portion of the total loading vec
tor be reduced with reasonable effort and expense?
• Would symptomatic treatment in the dental office be rea
sonable?

vectors is to differentiate
between conditions that can and
cannot be treated by a dentist.
Except in the latter instance, the
decision must then be made
whether dentistry is to provide the
sole treatment of the diagnosed
conditions or is to be part of an in-
terdisciplinary approach.

Continuous
pain

Episodic
pain

Deep pain Superficial
pain

Manual functional
analysis
Dental primary
dia
g
nosis
Other disciplines


Neurovascular
pain
Vascular pain
Glandular,
ocular, and
auricular pain

Pulpaf pain
Visceral
mucosal pain

Periodontal
pain
Connective-
tissue pain
Ostealgia m6
periosteal pain

jyjpaln
—
Neuropathic
pain
Physical
pain Migraine
with aura
Migraine
without aura

tive dental treatment plan. Every case in which a patient complains of craniofacial pain requires a
thorough gathering of information on the status of the teeth, periodontium and mucous mem-
branes, even when there appears to be no connection between the reported complaints and the
"typical" toothache. Beware of a superficially conducted "quick diagnosis" which always increases
the risk that essential findings and secondary factors will be overlooked, incorrectly evaluated, or
forgotten, especially when they seem to bear no apparent relationship to the patient's reported
symptoms.
Strictly speaking, the examination begins with the first
visual and verbal contact with the patient (physiognomy,
skin and facial coloration, posture, gait, speech etc.) Even if
not all the information is germane to the dental diagnosis, it
is the dentist's duty to identify, to the best of his or her abil-
ity, any symptoms that might indicate a systemic illness and
to motivate the patient to seek an evaluation from an appro-
priate specialist (Kirch 1994).
There are various techniques for eliciting and documenting
a case history. It is recommended that patients first be
allowed to begin describing their history of illnesses in their
own words. Because the description of previous illnesses
usually proceeds at an irregular pace, after a period of time
determined on an individual basis, the caregiver should
politely interrupt the patient's monologue and conduct the
consultation further by asking concrete questions concern-
ing the primary and secondary symptoms. Under no cir-
cumstances should these questions be leading or sugges-
tive. The diagnosis, treatment plan, and success of the
treatment are dependent upon correct interpretation of the
findings and therefore upon the knowledge and experience
of the clinician. A frequent mistake is the failure to discuss
not just the physical, but also psychological conditions as

pulp, periodontium, or mucosa can cause pain, varying in
degree from light to excruciating, to radiate to the jaws,
cheeks, eyes, or ears. The pain can be accompanied secon-
11 Intraoral inspection
Dentition of a 35-year-old patient
exhibiting severe damage from
caries and periodontal disease.
There is diffuse radiating pain in the
right half of the face.
12 Diagnosis of caries
Transillumination by placing a co!J
light probe (by EC Lercher) inter-
proximally reveals caries extending
into the dentin of the second pre-
molar as evidenced by the in-
creased opacity of the carious toot!
structure.
Right: The same region as in the left
photograph under regular lighting.
The proximal caries on the mesial of
the second premolar cannot be
seen without the help of a diagnos-
tic aid.
Contributed by K. Pieper
13 Fractured filling and
fractured dentin
A functionally inadequate filling
with poor marginal integrity is the
cause of dentinal pain.
Right: The dentinal fracture on this