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A Joint Exam

Part 1 - Palpation

Instructors:
Lee Ann Brady, DMD
Dr. Brady demonstrates different palpation techniques to assess the temporal mandibular joint.

I'm Dr. Lee Ann Brady. Welcome to your HDiQ video. I'm doing a joint exam. So this is really companion video to another video that we have on HDiQ going through joint anatomy and joint diagnosis. We wanted to give you an opportunity to really see the implementation of those clinical skills, those diagnostic exams so you have a chance to do this in your office. So I want to start by just thanking Katie for being our patient today, Katie is actually one of my dental assistance here, and Crystal for assisting in our video. And what we want to do today is go through the pieces and parts of a joint exam. And so Katie and I would have already completed a history. We would have talked about what she's aware of as far as joint sounds, challenges with opening and closing, any discomfort or signs and symptoms that she might have that could be relevant to what's going on with her joints before we would come back to the operatory and start our examination. The first part of our exam is going to be just to do some joint palpation for this. My preference is actually to do that without gloves on. So I'd ask Katie's permission to do that. Make sure that my hands are washed and clean before I do the joint palpation. So as we get started with that, one of the first things I want to do is observe Katie's opening and closing stroke. So what I'm going to do is I'm going to just visually find a landmark on the top jaw. So for Katie I'm going to use the center of the philtrum of her upper lip. And I'm going to find a landmark on her lower. So I'm going to actually use, Katie happens to have a freckle on her lower lip, so I'm going to use that as my landmark. And what I'm going to do is I'm going to ask Katie just to open and close for me several times. While she's doing that, I'm actually going to do several things at once. So the first thing I'm going to do is I'm going to observe how she's opening. What I'm looking for is does Katie open nice and smooth or does she stop and start other places where it's difficult or challenging for her to make that movement. I also want to watch whether or not her upper and lower jaws stayed lineup. So her opening and closing stroke is very up and down versus does she have a deviation, does she have to move her mandible to the right or the left or a combination thereof to get open all of the way. While I do this, I'm going to actually have my hands over the lateral pole of her condyles and you'll notice that I'm actually using three fingers from the middle of each hand. The reason I'm doing that is cause right now I haven't isolated her lateral pole. I want to feel for any palpable joint noises so are there pops or clicks potentially even some very coarse crepitus that I can feel under my fingertips. But it also allows me to isolate her lateral pole because the next part of the exam is going to be doing a lateral pole palpation. Okay so Katie if what you would do for me is just open and close about three times. And now is that as wide as you can open? Okay. Go as far wide as you can open. There you go. Okay. And what I'm looking at again is I'm watching Katie's opening stroke. From my perspective it looks like Katie opens very very smoothly so there is no deviation. So she does not have to move her mandible right or left in order to get open. I did notice, you know, normal opening. So when we think about how far someone should be able to open typical range of motion in an opening stroke is somewhere between 35mm-60mm. So the first couple of times Katie was opening I was just watching and sort of doing some mental mathematics and going I bet she can open wider than that. So I asked her to go ahead and open further cause I do want to see can she or is there some kind of limitation that was keeping her opening in that smaller zone and she was able when I asked to go ahead and open as wide as possible. Was that difficult at all for you? Did that hurt to open wider? No. Okay. So it's just a habit. Most people are not used to opening to the full extent of their opening stroke but we want to see that as part of the exam. At the same time as I was observing that I actually had my fingers over her condyle-disc assembly and I was not aware of any palpable joint noise. So there was no popping or clicking or crepitus that I could feel underneath my fingertips. So as I would be completing that exam, I would be then isolating her lateral pole. I'm going to have her do it one more time so that I can get to where I have one finger over her lateral pole. So Katie open one more time for me and close. And so now what I've done is I've follow the lateral aspect of her condyle which becomes more prominent when she opens back into a seated position. Now with one finger over her lateral pole, I'm going to go ahead and do this lateral pole palpation. What I want to do is I want press in and then release proximately 1 to 2 pounds of pressure is appropriate for a lateral pole examination. And then I'm going to get feedback from Katie. So prior to doing this part of the exam, she and I would have had a conversation about what to expect that she's going to feel pressure, that pressure is a normal part of the exam. And that for me when I do this exam, the only information I get is what she's going to give me as feedback. So if she feels anything other than pressure all the way from just mild tenderness to significant discomfort that she needs to give me that feedback and we're going to use a scale of 1 to 10 to rate how she feels about this. So Katie I'm going to go ahead and press in and let go and you tell me what you feel. Just pressure. So a zero. So if Katie had said it's a 2 or a 3 or 10, one of the things to make sure we keep in mind with those numbers is the only person it's relevant to is Katie. So if Katie tells me a 3 and the patient right before this I did the same exam and they said, oh, it's a 5. It doesn't mean that Katie's hurts less or that her joints are in better condition because it's pain perception. Everyone is in an individual and we have a different way of giving it that number. Now where that number would be relevant if Katie had said there is a 3 or a 4 or 5 what does a positive palpation response mean. What it means is that there's inflammation somehow in the capsule or the synovial membrane of her joint with a lateral pole palpation. So my differential diagnosis is a capsulitis or a synovitis. She and I might agree to do something therapeutic to try to treat that. We might try non-steroidal anti-inflammatories or Medrol Dosepak or probably most likely other than pharmaceutical we would actually work together on some kind of a bite appliance. What I want to know is is the therapy we're applying being successful at treating the underlying condition. The way I know that is by going back after she's in her appliance repeating the lateral pole palpation and expecting those numbers to be smaller. If I go back after she's been in an appliance a few weeks and I feel like its well-adjusted and those numbers aren't changing, I have to go back and question my original differential diagnosis. Maybe it's something else besides what we thought it was and we need to now be addressing a different therapeutic ways to address her discomfort. So that's a lateral pole palpation. You want to make sure we're talking in about 1 to 2 pounds of pressure. Very different than a muscle exam in the other video on HDiQ when we do muscle exam. We do use more pressure from the muscles. When we come to the joint, we don't want to get a false positive by pressing too hard. Over time you'll learn the right amount of pressure but one pound of pressure is just enough to make your fingernails blanch. So that's what I use as a way to know I'm doing the right amount of pressure. Once I've done her lateral pole palpation, next for me is going to be what we called retrodiscal tissue palpation. That's the highly innovative, highly vascular tissue that sits behind the head of the condyle in the joint space. In order to palpate that tissue I'm going to ask Katie to open as wide as possible. And now my fingers can actually fall into this little space behind the condyle. Now I can't truly get all the way behind the condyle. But I can get my fingers around the posterior lateral aspect of the condyle. So I want you to notice how I'm rotating my fingers so that they're facing forward and they're pressing in. And now I'm going to press again with one pound of pressure and let go and ask Katie how that feels? Pressure. So just pressure. So now if Katie had said that that was uncomfortable or tender, we would have a positive response to a retrodiscal palpation. That means we have there's inflammation to a retrodiscal tissue area. What could be causing that? Well there are a lot of things when I think about my differential diagnosis. I would wonder about potentially what are the things that could be distalizing her mandible. Does she have a function of envelop of function violation of the anterior. If she did, I might also see that I see positive digastric muscles when I do that palpation. So I want to start putting these pieces together from a standpoint of no one finding is going to tell me exactly what's going on. It's the combination of those findings that's going to be important.