Table 2: Cranial Nerve Screening Nerve Number Nerve Name
Function
Screening Test
Oculomotor c
III
Pupillary constriction, lifting upper eyelid, rotation of eyeball up, down, and inward.
Shine a light in the eye to observe constriction; have the patient follow a target (your finger) forming the letter “H” or “X” with his or her eyes.
IV Trochlear b V Trigeminal c
Rotation of the eyeball down and inward. Test together with oculomotor.
Sensation to face, cornea, teeth, gums, palate, and anterior two thirds of the tongue. Control of muscles of mastication.
Touch areas innervated by the three branches of the trigeminal nerve with a cotton wisp; touch the cornea of the eye with a cotton wisp; test sharp-dull discrimination of the facial skin with a toothpick and cotton tip. Check strength of masticatory muscles by having patient clench his or her teeth together.
Abducens b
VI
Rotation of eyeball outward.
Have patient look to the side.
Facial c
VII
Taste to anterior two thirds of the tongue. Control of muscles of facial expression.
Have patient detect differences in flavor such as lemon, sugar, and salt; have patient purse lips, close eyes, smile, frown, and show his or her bottom teeth. Check gross hearing by rubbing a strand of hair between your fingers or holding a ticking watch near the patient’s ear, or use a tuning fork; have patient walk a straight line. Touch the pharyngeal muscles to provoke a gag reflex; ask the patient to say “Ahhh”; observe the movement of the soft palate and ask the patient to swallow.
VIII
Acoustic/ Vestibulocochlear a
Hearing and balance.
IX Glossopharyngeal c
Sensation of laryngeal and pharyngeal muscles. Control of laryngeal and pharyngeal muscles.
X Vagus c
Same as glossopharyngeal. Control of trapezius and sternocleidomastoid. Control of tongue movements.
Test together with glossopharyngeal.
Accessory b
XI
Ask the patient to shrug the shoulders and/or turn the head against resistance (of your hands). Ask the patient to protrude the tongue and move it laterally (against resistance, e.g., a tongue blade).
Hypoglossal b
XII
a Sensory; b Motor; c Mixed Muscle and joint palpation
pain; if the mouth opening is still less than 40 millimeters, the clinician should gently try to open the mouth wider. If there is no “give,” the cause of the pain is likely intracapsular; if there is “give” to a normal range of movement, the cause of the pain is likely muscular (although this measurement should never be the sole indicator of a diagnosis). Lateral and protrusive movement should also be recorded, with a range of 7 millimeters or more considered normal. Intraoral examination The dental practitioner should also perform a routine intraoral examination, keeping in mind that a diagnosis of trigeminal neuropathic pain depends heavily on ruling out any other dental conditions. The intraoral examination includes components such as soft tissue examination, oral cancer screening, dental and periodontal evaluation, and occlusal evaluation. Because the intraoral examination is standard procedure for the general dental practitioner, details on how to perform such evaluations will not be addressed here. Additional diagnostic testing In some cases, more information is needed to arrive at a diagnosis. Depending on the differential diagnoses, these tests can vary from screening images such as periapical or panoramic radiographs to more advanced imaging techniques such as cone beam computed tomography (CBCT) or magnetic resonance imaging (MRI), from topical anesthetic to nerve blocks or even sympathetic nerve blocks, and could include laboratory testing when suspecting, for instance, hematologic, rheumatologic, or autoimmune diseases.
Masticatory and cervical muscles should be palpated with either pinch palpation (e.g., the trapezius and sternocleidomastoid muscles) or flat palpation (e.g., the masseter and temporalis muscle, medial pterygoid, and temporal tendon). The palpation should be done with enough force to blanch a fingernail. Palpation in this fashion may result in the patient reporting pain or tenderness. The clinician may be able to feel sensitive, ropy, taut bands in the muscles, which are called trigger points . Pressure should be applied for 5 to 10 seconds on these points to determine whether palpation results in referred pain to other structures. The palpation is performed to identify the source of the pain and to reproduce “familiar pain” about which the patient came to consult. Familiar pain may also be elicited by jaw function, such as clenching the teeth together or opening the mouth wide (Lovgren, et al., 2019). The lateral pterygoid muscle is difficult to palpate. This muscle can be tested by allowing it to contract against resistance. The patient is asked to move the jaw to one side while the clinician holds the jaw to resist this movement. This action allows the muscle to work without movement of the temporomandibular joint. Movement of the temporomandibular joint at the same time could result in a false positive recording. The temporomandibular joint is palpated from the lateral aspect at rest and during mouth opening. The clinician records pain from palpation; pain from opening, closing, and lateral movements; and the presence of joint sounds (e.g., clicking, crepitus) during such movements. The clinician should also record the point at which the movements stop being comfortable and begin causing
TREATMENTS FOR CHRONIC PAIN
Chronic musculoskeletal pain is often targeted with a variety of treatments, all aimed at creating conditions most likely
to promote repair and recovery of the affected tissues. For temporomandibular disorders, this means unloading the
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