Editor's note: “Patient History 101” is a series of four articles from Dr. Jim McKee with advice on how to obtain accurate and helpful patient history. Read his other lessons here:
• Lesson 1 (Jaw Joints)

The first article in this “Patient History 101” series detailed the three common presentations of jaw joints in clinical practice:

  1. Structurally intact jaw joints. This is classified as a Piper Stage 1, which is a normal joint, or a Piper Stage 2, which is a joint with beginning ligament laxity at the lateral pole.
  2. Jaw joints structurally altered at the lateral pole.
  3. Jaw joints structurally altered at the lateral pole and the medial pole is classified as a Piper Stage 4A, which is a joint with a torn ligament at the medial pole and a torn ligament at the lateral pole. This type of joint clicks at the medial pole upon opening. A Piper Stage 4B is a joint torn ligament at the medial pole and a torn ligament at the lateral pole and does not click at the medial pole upon opening since the disk has deformed.
Three digital images of a lower jaw, side by side. The first with a green dot, the second with green and yellow, the last with yellow and red dots.
Figure 1: Three common presentations of jaw joints and Piper classifications: (far left) “structurally intact” - Piper 1, 2; (middle) “structurally altered at the lateral pole” - Piper 3A, 3B; and (far right) “structurally altered at the lateral and medial poles - Piper 4A, 4B, 5A, 5B.

The Piper 4A/4B and 5A/5B joints are typically considered moderate-high risk joints because the disk is not covering the medial pole. The medial pole is the load-bearing portion of the temporomandibular joint and the disk at the medial pole maintains the vertical dimensions at the level of the TMJ.

The Piper 4A/4B, 5A/5B joints have an increased likelihood for pain, bite changes, or both. The goal is to recognize the high-risk joint patients (Piper 4A/4B and 5A/5B) before beginning any occlusal, orthodontic, restorative, orthognathic, or airway treatment.

The key factor in joint stability is the soft tissue (disk) functioning against the hard tissue (condyle/joint socket) at the medial pole. High-risk patients (i.e., Piper 4A/4B, 5A/5B) present without soft-tissue coverage of the condyle at the medial pole. The ligament attaching the disk to the condyle at the medial pole is torn in these patients. While there have been different theories proposed on the cause of disk displacements, the prevailing thought today is that an injury results in the torn ligaments similar to other orthopedic joints, such as the shoulder or the knee.

My Lesson 1 article explained how to obtain an accurate “history of the joints.” Now, obtaining an accurate “history of injuries to the joints” is emphasized.

In most cases, we ask patients if they have ever experienced an injury to the head or neck. Most patients do not report any injury to the jaw joints. However, some joint injuries occur earlier in life than injuries that occur in other orthopedic joints.

There are typically three types of joint injuries:

  1. A compression injury, such as a fall in which the patient struck their chin, or an incident in which they caught an elbow to the jaw during an athletic event.
  2. A whiplash injury from a car accident or incident like a fall to the ground.
  3. A stretch injury, such as surgical intubation or extraction of third molars.

Questions for injury history

Have you ever been in a car accident?

How many car accidents have you been in?

How fast were you going at the time of each accident?

How old were you for each accident?
If patient answers any of the following – multiple car accidents, car accidents faster than 20 mph, or car accidents before 18 years of age – there is an increased chance for a Piper Stage 4A/4B, 5A/5B joint.

Have you ever had a concussion?

How many concussions have you had?

How did each concussion happen?

Have your symptoms resolved?
If patient answers that they've had multiple concussions or a concussion before 18 years of age there is an increased chance for a Piper Stage 4A/4B, 5A/5B joint.

Have you ever had sutures in the head or neck area?

Why did you need sutures?

Have you ever had sutures in your chin? How old were you when you had sutures in your chin?
If patient answers that they've had a chin impact or earlier facial trauma there is an increased chance for a Piper Stage 4A/4B, 5A/5B joint.

Have you ever had surgery with a breathing tube?

How many times have you had surgery with a breathing tube?
If patient answers any of the following – multiple intubations or intubations early in life – there is an increased chance for a Piper Stage 4A/4B, 5A/5B joint.

Have you had your tonsils and/or adenoids removed?

How old were you when your tonsils were removed?
If patient answers affirmatively then they most likely have a stretch injury, which can lead to an increased chance for a Piper Stage 4A/4B, 5A/5B joint.

Have you had your third molars removed?

At what age were your third molars removed?
If patient answers affirmatively then they most likely have a stretch injury, which can lead to an increased chance for a Piper Stage 4A/4B, 5A/5B joint.

Did you participate in contact sports in your growing years?

Do you remember any head contact while participating in contact sports?
If there was an increased risk of compression or whiplash injury there is an increased chance for a Piper Stage 4A/4B, 5A/5B joint.

Did you have any falls onto your face before your 12th birthday?
If there was an increased risk of compression or whiplash injury there is an increased chance for a Piper Stage 4A/4B, 5A/5B joint.

Have you had multiple injuries?
The more injuries and the earlier in life the injury occurs, the higher the risk level for a Piper Stage 4A/4B, 5A/5B joint.

 

 

Jim McKee, D.D.S., is a member of Spear Resident Faculty.

References

Piper M. Temporomandibular Joint Imaging. In: Handbook of Research on Clinical Applications of Computerized Occlusal Analysis in Dental Medicine. Hershey, PA: Medical Information Science Reference; 2020:582-697.


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