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-- see also:  "Interpreting patient responses"


Most of these 28 Flash videos are one mintue or less in length (They were recorded at the "NTI Summit in St. Louis" held at  Keller Labratory).   The entire interview series will soon be available on a DVD.  (each video will continue to loop until you exit its window)
A) Initiating the Interview: Establishing the Patient's Baseline
B) Objective Verification
C) Recognizing the Headache Sufferers who are already your dental patients
D) Associating Parafunctional Acts with Signs and Symptoms
E) NTI Initial Delivery Protocol
F) Interpretations of Re-Evaluation


 


A) Initiating the Interview: Establishing the Patient's Baseline
Sufferers discount their condition. An irregular occurrence can be a sign of a varying sleep pattern.

Establishing what is unusual to the patient. What might seem like a  headache to one person, could be an opportunity to "get some things done" to another.

The rationalization for their pain. By definition, chronic headache and/or migraine is diagnosed due to the
absence of objective findings.  Patients must then assume that "something"
is the cause or reason for their pain.

What not to ask at initial consult. Asking "When you wake up, do you feel fabulous?" is far more informative that asking, "Do you get headaches?".

Waking up with a "zero" is weird. In the patient's scale of pain, a low number can be normal and unremarkable, which is
why they are asked if they "feel fabulous" (a "3" may not be considered a headache.

Pain upon waking is just part of the picture. Chronic nocturnal parafunction maintains the environment that can trigger into an attack at any time.

The range of headache
intensities.		 Although this is an extreme example, establish what the patient's "usual and customary" headache pattern can be.

How the pain can intensify rapidly. One minute the pain seems tolerable, or is not there.  The next minute, it can overwhelm them.

What they do dictates
their presentation.		 The pattern of the parafunction influences the nature of the function and symptomatic presentation.

B) Objective Verification
Palpation provides evidence of an underlying condition. Chronic headache and migraine sufferers have pericranial tenderness.  Even when not having a headache, palpation will elicit a response and may even initiate a headache.

Recording objective palpations. In chronic headache and migraine, the only recognized objective evidence is pericranial tenderness.

C) Recognizing the Headache Sufferers who are already your dental patients
NTI candidates are already dental patients. When doing a re-call exam, simply ask the patient, "When you wake up in the morning, do you feel fabulous?"

The secret life of a chronic migraineur. Some chronic headache sufferers simply endure their pain.  They do their hair nicely,
dress well and go about their lives.  They go get their teeth cleaned, and they go to the store...and when no one is looking, take another pill or Imitrex injection.

Clinical clues to a chronic clenching disorder. Lower molar won't get numb?  Teeth sensitive to cold?  Can't stay open during a prophy?  "Say, when you wake up in the morning..."

D) Associating Parafunctional Acts with Signs and Symptoms
Protrusive clenching
and cervical effects.		 As odd as it might seem, patient's do unusual things with their jaw while asleep,
resulting in unusual symptomatic presentations.

Protrusive clenching
and sinus effects.		 If someone were to actually clench in unusual jaw positions, the resulting symptomatic presentation reflects the specific efforts made by the responsible musculature. 

How "stress" can cause pain Chronically fatigued spindle fibers within certain musculature may "spasm" following
elevated sympathetic activity.

E) NTI Initial Delivery Protocol
Protocol upon initial NTI
delivery.		 Delivering a lab provided NTI-plus (from Keller Lab).  

Intense biting on the DE
shouldn't hurt.		 Assume that the NTI is uncomfortable upon initial delivery, so that the patient
does not hestitate to inform you of what needs to be altered.

Migraineurs don't get used
to irritants.		 Adjust the internals and the Discluding Element as necessary so that the NTI
feels like "a part of their head" instead of "a thing on their teeth".

Recognizing normal vertical
and adequate retention.		 When there is too much vertical opening, the patient may appear "fidgety". 
The device can not be removed without the patient using their hands.

Class III edge-to-edge probabilities. The degree of incisal overlap prior to NTI use can dictate if seating of the
condyle is clinically noticeable as an opening of the anterior bite.

Not getting lip seal is not a
function of vertical.		 Sometimes, a patient will report, "I can't close my mouth", when actually they
can't get lip-seal.  Reduce the labial bulk rather than closing vertical.

Parafunction does whatever it
has to.		 Upon delivery, check to see what "extreme" positions the patient is capable
of, and modify the Discluding Element accordingly.

"The condition" tells the patient
to "do" something.		 A typical posture for the patient is to have their teeth occluding.  They need/want something to "do".

F) Interpretations of Re-Evaluation
The first question to ask at the re-eval. If you ask, "How are your headaches" at the first re-evaluation, you might be mislead...

The foundation of the chronic headache. Rather than providing relief from a specific migraine attack, the dentist's role is to reduce the influence of an underlying condition, thereby reducing the frequency and intensity of attacks.

Knowing when to increase vertical. Sometimes, the headache intensity is only decreased, but just as frequent.