Our patients give us many diagnostic clues if we just take a few moments to observe them. The only difference between Fig 1 and Fig 2 below is the patient is opening her mouth widely, something we as dentists ask of them constantly. To do so, she has tipped her head back rather than just move the mandible. In physical therapy language, she is recruiting the sub-occipital musculature to help her open the mouth.
|Fig 1||Fig 2|
Does this matter? Let’s consider what is happening. The lateral pterygoid muscles plus the supra and infra–hyoids are not able to manage to open the mouth fully on their own without the assistance of the sub-occipital group. For the most part the patient gets by on a daily basis by avoiding anything requiring such a degree of opening. However an extended dental visit pushes her past that restriction. In the dental chair, because of the headrest, she is unable to tip her head back to assist with opening.
Many patients report that they manage on a daily basis quite well except for the several days after an extended dental visit. Opening the mouth even to a limited extent suddenly becomes uncomfortable or painful. The solution is to place a rolled-up towel under the neck during the appointment so that the patient can let the head drop back due to gravity. Stopping every five minutes to let them relax is also helpful. However, the mandibular restriction on opening may be a sign of more generalized difficulties.
More than a 100 years ago, the famous Canadian physician Sir William Osler said “listen to your patients, they are giving you the diagnosis.” I would add, “observe your patients’ movements, they are giving you valuable information.” This particular pattern of movement may not be of importance for any specific patient but even a few casual questions enquiring about postural problems such as back discomfort, headaches, occasional difficulty in swallowing, the avoidance of hard foods etc. are worth asking.
Often, it turns out that they have been attending a massage therapist, chiropractor, physical therapist or osteopath for years but only receive temporary relief. This should be a red flag for further oral investigation. The difficulty for us as dentists is remembering that oral parafunctional habits develop to meet a need somewhere in the body. In the new thinking among biologists and biophysicists the body is recognized as being remarkably energy-efficient. It does not like to waste energy. Our job therefore is to work out if there is a dental contribution we can make that will help resolve the larger problem.