A Clinician’s guide to TMD Management
Walkthrough of the latest TMD Guidelines with the authors!
What’s the right approach when a patient presents with both acute and chronic painful jaw symptoms?
How can the latest RCS guidelines simplify your diagnosis and treatment process?
In this episode, Professor Justin Durham and Mrs. Emma Beecroft join Jaz to unpack the latest Royal College of Surgeons TMD guidelines designed specifically to help GDPs navigate these tricky cases. Together, they explore practical strategies for managing TMD, breaking down the step-by-step flowchart that makes handling these cases less intimidating.
From understanding the key principles to applying them in everyday practice, this episode will help you feel more confident in delivering better patient care for TMD.
https://youtu.be/R0NaBJr5g5E
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Protrusive Dental Pearl: Important takeaway: Download the New TMD Guidelines
Need to Read it? Check out the Full Episode Transcript below!
Highlights for this episode:
This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.
This episode meets GDC Outcomes B and C.
AGD Subject Code: 200 OROFACIAL PAIN (Diagnosis and treatment)
Dentists will be able to –
If you loved this episode, be sure to check out this episode: TMD Full Exam with ‘The TMJ Doc’ Dr Priya Mistry – PDP064
Click below for full episode transcript:
Teaser: A standard extroral exam involves, the examination of temporalis and masseter, which are the only two muscles that international recommendations would suggest.
Teaser:
So you don’t need to bother with that lateral pterygoid because you’ve got to be, have a bit of a strange finger to reach it, firstly up and around the back of the tuberosity and not evoke kind of vomit on your shoes.
And a medial pterygoid similarly, it’s not a very nice place to have palpated. And actually the vast majority of the diagnoses have been made with pressing on masseter and pressing on temporalis.
When you ask them to open to where they feel comfortable, anything less than 35 millimeters is restriction. For the acute restricted opening, anything 10 millimetres or less. So if they can’t get a finger between their teeth, that’s the ones we’re kind of more worried about from an acute restricted opening. Sometimes overrunning by 10 minutes to allow someone to feel heard, to be really clearly explained to them why they’re getting their problem can be what they need to get over the hurdle.
Not everyone needs to be in RCP and not everyone needs canine guidance group function. If they’ve already got group function, it’s fine. What they need is smooth and easy movement across the occlusal.
Jaz’s Introduction:
Finally, some decent guidelines for TMD. Have you checked out the new TMD guidelines? This is exactly what today’s episode is about with Professor Justin Durham and Mrs. Emma Beecroft. They’ve joined me on the show today to discuss the 2024 RCS guidelines for the management of painful temporomandibular disorders, which let’s face it, as GDPs, it can be very confusing for us and very scary for us.
In the episode, I likened it to like trauma. When someone comes in and they’ve evulsed a tooth, we’re like, ah, okay, very time sensitive and it’s something that I haven’t done in a long time. What do I do? I pick up the guidelines. I pick up the trauma guidelines which will be a step by step to guide me on what to do. What’s best for my patients.
We also have some wonderful periodontal guidelines, and now we’ve got a lovely flow chart to follow for TMD. The main mission of today is to get you, and this is the Protrusive Dental Pearl, by the way, this is the most important pearl I can give you, which is to download all the free resources I’m putting below.
Okay. So whether you’re on Spotify and you read the description, YouTube, Protrusive Guidance, wherever you’re watching or listening to this, okay. Please make sure you take some time out today to download the guidelines. In fact, I’ve made it very easy. You don’t have to download individual PDF files. I made a zipped folder with the three main PDFs to talk about today, which is the patient version, the dentist version, and the full guidelines, for a really- want to put yourself to sleep.
You read those ones, but the summary document is actually really fantastic. And the patient one is honestly worth its weight in gold because the main thing is we don’t want to reinvent the wheel. Why are we giving our own practice branded guidelines for TMD? There’s no need to give your patient the document that your practice wrote about all the exercises they should do. Why don’t we show them which exercises to do. So what the guidelines for the patient has is a QR code that takes them to the videos where Emma herself, one of the guests of the podcast today is there showing the patient how to do the exercise.
And these are the latest guidelines. So I would say replace your current and existing documentation on TMD with this one, which is the latest and best advice with the videos. So patient’s not guessing anymore and how to actually do those exercises. In that zip folder, I’ve also added a video of how I deliver a soft bite guard, because that is the most accessible, the cheapest guard, which may help patients in acute pain.
And seeing as so many of us are already prescribing soft bite guards, which I don’t do so much of, but I know that this is the most economical and sometimes the speediest way to get someone care. And when I do these, there’s a specific protocol I follow of heating the splint to get even contact. Think about it.
When you give a soft bite guard, they are not balanced. So I’m going to show you a quick and easy way to get the balance. So that video is in there and any other goodies I can think of at a time of me assembling it. So you can download that at protrusive.co.uk/tmd, that’s protrusive.co.uk/tmd those goodies are there for you for free.
Now, before we join the main episode I just really need to emphasize the following; which is the supported self care part in there is the most important thing right? Let me explain why. There are so many different schools of thought for how to manage TMD. This is why patients get confused. This is why we as a profession are a little bit confused. There are colleagues who actively recommend orthodontics as the first line to manage TMD. There are colleagues that swear by neuromuscular methods and TENS or BOTOX as first line.
Well, I would say that the first line should always be supported self care. The foundational advice that you give for any type of joint injury, taking the load off. Applying heat, applying ice, self massage, there’s so much to it and it’s been all compiled in that document that I mentioned. So whilst I was lucky enough to have these two guests on today, I didn’t want to spend too much time on that because that is available to you and you should be giving that to your patient as first line.
Now a lot of what we discuss will upset some clinicians because we may have simplified it or dumbed it down. But the evidence supports that the basic stuff done well, done early, will yield a positive response for the vast majority of patients. And it reminds me of a Jeff Okeson quote. Jeff Okeson is like the OG, the legend of TMD education.
He says that when there’s so many different schools of thoughts in terms of how to manage TMDs. There is a core in the middle, which is like the evidence based stuff. The safe and reversible stuff that we could all do. And then there’s stuff that’s out there, which is a little bit on the fringe. And you know what?
There is a place for it. I do some things which are on the fringe, but I only do them once I’ve exhausted everything in the middle. Everything that is reversible, everything that is cost effective for the patient first. Things like a timely physio referral or counseling for awake bruxism. These things are incredibly powerful.
Then there might come an appliance, and then we reassess. And then if that doesn’t work, then we’re edging more and more towards modalities that may not have as much evidence, that may be a little bit more aggressive, or more of a risk of a bite change, and there’s okay, there’s a place for that. Because that can help our patients, but I would not do that without a bedrock, without a foundation of supported self care.
So Protruserati, let’s simplify, let’s simplify TMD management. Let’s disseminate these guidelines. Let’s download them. Let’s read them and let’s put them into use. So next time you had that TMD emergency, you know exactly what to do. And in your own patients who need your help, you know that you are following the latest evidence based guidelines and getting it right first time. And for those non responders, there’s always pathways available as well. Hope you enjoy this episode. I’ll catch you in the outro.
Prof Justin Durham and Mrs. Emma Beecroft, welcome to the Protrusive Dental Podcast. I’m so excited to talk about this topic, which is very, very close to my heart and mind, something I think about a lot, something I’ve been on multiple courses for over the years.
And I think about this a lot. I see a lot of patients around this, and I really want to contribute to help dentists to help their patients. And I’m particularly excited because what you’ve produced with the guidelines is absolutely brilliant. The main guidelines are 85 page. It’s so detailed. It’s such a lovely summary of all the other guidelines I’ve seen and other evidence based out there.
So truly remarkable job. And then you’ve got the eight page clinician summary, and you also got the patient summary. And I will make that available. Obviously it’s already available freely to download, but I’ll just make it very easy for everyone to download. And some of those who are perhaps sitting down, watching, listening, they can actually follow along as we’re discussing, but we’re going to make sure that if you’re on the train, if you’re jogging, if you’re rocking a baby and you’re listening along, whatever you’re doing, you can follow along and you can gain from this, but before we delve any further, introductions, please.
Prof, I’ll call you prof one more time. And then it’s Justin. So, Justin, please introduce yourself, tell us about yourself and where you work and how you got into this deep and dark world of TMD.
[Justin]
Yeah, I’m not sure it would be a dark world, and I do think that if you are rocking a baby, the guidelines might put you to sleep over 85 pages. So I think the first thing to say would be, we are actually about to, as a result of some feedback, produce a two page ultra brief guide so that people can kind of pick it up and know what to do almost immediately to go alongside the flowchart. But I digress. I think firstly, TMD is not a dark world.
There’s quite a lot of evidence about TMD. It’s just not very well communicated, and that’s what these guidelines supposed to do. I am a professor of oral facial pain and an honorary consultant oral surgeon, and I’m based at Newcastle University. That’s who employed me in Newcastle hospitals, where I have my honorary consultant practice.
I got into TMD because I got it. So I suffer from myalgia temporomandibular disorders, muscle based pain, and I suffer from a displacement without reduction with intermittent locking, which is a posh way of saying occasionally I can’t open my mouth as wide and it’s very painful. And that’s down to the fact that a bit of cartilage moves in and out of place.
So I got into it because of that. And that was about scarily nearly 25 years ago now. And it was in my sort of house jobs as they were, a new money. I forget what that’s called. Emma, what’s a house job nowadays? Is it dental core training? I think general professional training, that type of thing.
Cause no one seemed to be interested in TMD. And I had it and no one seemed to be interested and it always seemed to be that, you were the house person, the senior house officer, the general junior house officer, and you were given the patient to look after and care for and there wasn’t a lot about. So that’s how I got into the area and that’s why I went off to do a PhD in it. And that’s kind of my background, I suppose.
[Jaz]
Do you play chess, Prof?
[Justin]
Badly and not regularly.
[Jaz]
The reason I ask that is because one thing that I heard Jeff Okeson say once is like TMD is a thinker’s game, right? And you’re very prolific in this field. Every time I attend even like an American webinar, your name pops up somewhere. And so your reach is amazing. Your authority in this is fantastic. So a great privilege to have you on, but you are a true thinker. I can see that. And you are a true clencher. I can see your right master popping as you’re watching that in front of me. That’s why the locking happens. Emma, please tell us about yourself.
[Emma]
Thank you. And so my name is Emma Beecroft. I’ve been working with Justin for probably about 15 years now. Justin, it feels probably a lot longer for you.
[Justin]
Are we including your undergraduate degree as well or?
[Emma]
No, no. So let’s just not add that on. So I work at Newcastle Dental Hospital. I am doing my oral surgery specialty training. I’m doing an academic training. So I’m doing a PhD, which is in pain at the moment. And I loved working on the persistent pain clinic with Justin. And I’ve been doing that for a long period. And the reason that I liked it is that I think for both patients and clinicians, sometimes when people used to say TMD, there were kind of deep sighs and a lot of worry about, Oh, we’re not really sure what to do with it.
And for me, it’s about the person. And so there’s a lot of, with pain, it’s individual to that individual person. So we get kind of break down individually, what’s the important bits for them, make positive change to a condition that previously, maybe there wasn’t as much that we could do for it. It’s really nice to see how you are excited about TMD.
Because for dentists that doesn’t always happen and Justin and I are trying to kind of blow the trumpet to make people excited about it because it’s something that affects such a large range of the population. We know that with facial pain that the impact, so if we had the same injury or the same level of discomfort anywhere else in the body, it would impact you less.
Because the body protects the head and neck region. And so then it’s really important that we manage pain really, really well. I’ve just passed my board exams in America for orofacial pain. And so I’ve just done that and that was a relief. And then moving forward, it’s just working. Thank you. It’s working alongside Justin to try and make positive change for patients that have this condition.
[Jaz]
I really applaud you just for your focus in this topic and your motive behind it. It’s very clear that you want to make a dent in this and we really appreciate that. And it shows the hard, incredible hard work you’ve done to produce, help to produce the guidelines. So from the community and the profession, thank you so much.
And you raise a good point that dentists shy away and it’s not just dentists. I had Andrew Sidebottom on once, Nottingham based maxillofacial surgeon. He’s very much respected in his field. And he even said that, look, in the maxfax department, when the TMD folder comes around, they all kind of pass it around to each other.
And so, you know, it starts from primary care. Let’s get that sorted. And then, hopefully it’ll trickle upwards as well. My own personal journey, just to spend 30 seconds, is through wanting to better myself as a general dentist in the occlusion side. So, if I’m doing single tooth dentistry, if I want to now do two teeth or a quadrant or do a full mouth, occlusion 101 is okay.
Do an assessment of the joint. Are we going to have an unhealthy joint that needs sorting first? Before we do any occlusal work and through learning about assessing the joint, what is health, how do you get someone healthy enough to have the restorative dentistry is how I got into this. And then, some early wins I had in my career whereby patients come back and years of headaches were much better, or they’re now able to open much better or chew comfortably.
That was incredibly rewarding. I don’t limit myself to TMD. I’m very much a general dentist. A restorative dentists, but I would love to help all general dentists through this podcast to just feel a bit more confident because I feel as though TMD is this kind of thing. And using again, TMD umbrella term, by the way, just making it clear, we’re using it as an umbrella term.
We’ll, we’ll dive deeper into that, but it’s a bit like trauma when dentists get trauma through the door, because we see it few and far between, we kind of panic and then thank goodness we have some trauma guidelines to look at to help guide us, right? Because in that kind of moment, we need some clarity and I think the guidelines that you’ve produced give us that through the flowchart and I think with the Perio Scientists BSP having a guideline, it really helps dentists a lot.
So do you think that the issue we have with TMD being scary or TMD being not a hot topic. Like for example, if you put a course on veneers or composites, that kind of stuff, okay, young dentists will start queuing up for it, right? But I found personally that when people put on TMD events, they often get cancelled. And if you’ve seen they got their cancels because they don’t get enough bums on seats. So why do you think this is the case?
[Justin]
I think largely because there’s so much uncertainty and Henry McKay, he’s either probably still practicing professor of anesthetics or, or may have just retired. Oxford talks about chronic pain is common, but it’s not sexy.
And that’s no comment on Emma or I’s appearance on your screen. For those of us who can see us, obviously we are both extremely sexy, but the topic matter isn’t sexy. And the reason it’s not sexy is because there’s a lot of stigma there. People are still clutching to the 1980s, 1990s perspective of what was called TMJD or facial arthromyalgia and think it’s difficult.
It’s only difficult if you layer it up in complexity and what Emma and I, and various other people have been trying to do on this guideline is to take away some of the complexity and make it easier. Because if you treat a TMD patient, again, treating it as a global term rather than the specific diagnosis, if you treat them early in their course, so just after they’ve started to get symptoms, then they will do very well with very simple things.
So I think that’s kind of the message we want to push out to the community is that there are easy things that you can do. And whilst we understand that general dental practice is not a bed of roses, and it’s also quite a difficult place to work at the moment, I suspect, there are some simple things that you can do. There are some high quality materials that we’ve produced that are free, that you can signpost patients to and get patients to do things that will help them quite quickly.
[Emma]
I’d like to add to that as well, if it’s okay. So in addition to what Justin said, I think, I don’t know when people who are listening graduated, but I can really remember going through finals and trying to memorize the table from the RDC TMD, which felt so complex that we had so many subdivisions about what it means.
And so even from then, I felt like I never really got a grasp. I didn’t feel confident in my understanding. It had to start that way. So the academics had to kind of try and work out what was causing and all the different types of TMD. But when it started very complex, then we’re almost kind of backstepping now to say, you don’t need to definitely know which one of all the sub diagnoses it is.
If you can give us a broad category and you know you’re treating either a muscular or a joint problem. We’ve simplified it slightly so that they can feel confident in their delivery of the next step. So I think maybe the history of where TMDs come from academically, we’ve maybe not helped ourselves making it sexy.
We may be, it felt over complicated. And then I think the other thing is that we need to be really understanding of is that people in the healthcare profession want to give a fix. You just said earlier, you’re so excited when you got the patient that came back, the headache was better. You got the patient that came back, the bite felt better after you might have made some changes.
When I, from an oral surgery perspective, take out a painful tooth, they come back, they’re not in pain anymore. Feels good. We want to fix. And though the vast majority of time, we can make huge positive steps with temporomandibular disorder. There isn’t a one size fits all where I can definitely give you one thing that will definitely get rid of the problem.
And so it’s about managing pain and moving away in some situations from the discussion of a cure. It’s about managing the condition. And that feels maybe not what we usually do as healthcare professionals, or perhaps it’s a flick of mindset for us. So maybe that’s why it’s not as sexy as something else.
[Jaz]
Great addition. And when I look at the different resources that you put in the guidelines, one of them was the TMJ Association. I believe you linked them. Did you link to TMJ? Was I make that up?
[Justin]
Yeah. Yeah. Oh, we do.
[Jaz]
Yes, there we are. TMJ. org. Yeah. Brilliant. The reason I bring that up is the story behind the lady who I believe passed away just last year, her husband’s now taken over, if I’ve got it right, is she was a sufferer and she was just appalled by the lack of pathways and guidelines.
And she compared it to gynecology, for example, in medicine, whereby they got such clear guidelines and pathways. And her mission was to prevent patients having aggressive treatment. And so the kind of roundabout way I’m going here to ask you is one of the reasons, one of the other reasons why perhaps you find it so scary and confusing is because we’ve got very eminent authorities and figures around the world lecturing, and they’re all coming about from a very different angle where it would be at neuromuscular, be equilibration, but be it, let’s just focus on the airway and the TMD will fix itself kind of thing. So there’s so much out there. Orthodontics being suggested as certain types of orthodontics being very curative of TMD.
So as a clinician, young clinician, we’re scared. Like, okay, what did we learn? It seems so vast. Do you think that has contributed to the fact that there’s so many different alleged pathways that claim to be the cure?
[Justin]
Yeah, absolutely. And that’s why we produce something that was hugely based on the evidence and what the evidence says or doesn’t say. And I think that’s what we’re trying to do with a campaign that’s about to launch in the next couple of months called TMD think 3D. Detect, diagnose, and deliver self management because if you’re doing that in a de novo, a brand new TMD patient, as long as you’ve excluded red flags, as long as you’ve looked at it and you’ve done a full exam.
And you think that’s TMD, you will do very little harm by starting self management. You can always get another opinion as well. And I think the problem with more irreversible therapies is that the evidence base doesn’t allow us to know who they’re going to work on and how well they’re going to work.
That’s why you start with the do no harm principle by the fact that between 75% to 90% of TMD patients over the last 30 to 40 years, the research says that they will get better with simple self management techniques and good quality education around the do’s and don’ts and the simple things that they can do to help themselves.
And therefore, that’s why we would always suggest starting with that. And actually, that doesn’t stop you from building on other treatments. In fact, if you don’t start with that, lay a foundation, if you like, to build the rest of the house on, then you’re on hiding to nothing, essentially, because the patient is always going to need to have that foundation to fall back on, because it is, as Emma said earlier, it can be recurrent, it can be persistent in some level, so they’ve always got to have some strategies to manage if it waxes and wanes, or if the pain goes up or goes down, it’s similar as if you’ve hurt your leg or your arm doing repeated sports over the years.
You know, the ways that that might flare up and that you might then manage it. And then, you know, the kind of time period for healing and the course of the healing and how it might look. So I agree with you, Jaz. I think it isn’t helped. And that’s why we’ve A done these guidelines and we’re about to launch, as I say, ThinkTMD, Think3D, which is an international campaign about detect, diagnose, deliver self management because we recognize, as Emma said earlier, it’s way too complex.
And it doesn’t need to be that complex for the level of someone who’s initially in general medical or general dental practice, and they want to start to do something for their patients. And the lady that you referred to is Terry Cowley, who did pass away earlier in autumn, and who was a phenomenon in her own right, and is sadly missed.
And we’ve worked with her and the temporandibular joint association for many years now, and they do an awful lot of good and they’ve got a lot of useful information. The thing I would say is, is they are based in America. So a lot of the American challenges that they face within their healthcare system in America, we fortunately don’t face in the UK. So just if readers or listeners or watchers are going to that website. Just bear in mind that they’re facing a lot of different challenges in America than we do in the UK.
[Jaz]
And you made reference to the early referral, looking for red flags, I just want to highlight that and page six of, I mean, in the full guidelines, there’s loads on it, but even just page six is a lovely table, table three, which just gives you great a little quick reference into when we should be referring. And on that note, when the patient walks into your clinic, the kind of TMD patients that general dentists will see, they are acute emergency, like the emergency appointment, in our practice, we have half an hour blocked out for emergencies and the time where people sometimes WhatsApp me saying, Jaz, can you help? I have an emergency booked at 4. 30. I try to not say 2. 30. There’s a real emergency booked at 4. 30. What do I do? It’s TMD. I what I’m doing, kind of thing. So dentists get very worked up about the TMD emergency. They’re kind of like, I don’t know what to do.
And so the other one is the patient who’s been suffering for a long time, the chronic pain, and then they end up getting a referral. But it all starts with getting a good diagnosis. My big worry about this podcast episode is we spend so much time on the diagnosis that we don’t get onto the other bits.
So I’m just going to say that everyone just needs to download these guidelines, make a big pot of coffee, right? And just go through it all because it is absolutely wonderful. But I’d like to just spend a little bit of time through each step. Okay. So your patient attends with signs and symptoms suspicious of TMD.
And the first step you’ve suggested is, okay, let’s do the three QTMD, which will come to the CPI and the PHQ 4. That already can the dentist who’s only got a 10, 15 minute slot can seem a bit scary in terms of how much it needs to be done. So my first question to you is, when we see a new patient who’s not a TMD emergency, let’s say, when we see a new patient, we do mouth cancer screening, we ask about smoking, alcohol, we ask about all this, should general dentists around the world be adding in the 3Q TMD, like, as though it’s part of their medical history as well?
[Justin]
Not unless they’re suspicious that there’s some facial pain going on that they don’t think is related to the teeth, realistically speaking. So, if the patient hasn’t got facial pain that, I’ll change that around actually because I’m going to give you a double negative. If the facial pain is attributable to the teeth, then it’s attributable to the teeth.
And if you’re confident on that, then you don’t need a 3QTMD. If you think, oh, I’m not sure, then the 3QTMD is pretty straightforward. And it only requires one to two positives for you to say that this is quite likely to be TMD and the negative predictive value for people who are a bit geeky like me is in the 90%+.
So it’s very unlikely it isn’t a TMD if they do screen positive and there’s only three questions which are, do you have pain in your temple, face, jaw, jaw joint? Do you have pain once a week when you open your mouth or chew and does your jaw lock or become stuck once a week or more? And there’s an electronic calculator that you could give to the patient to do in the waiting room if you’re going to bring them back free or what have you.
You can also get the code off us and you can embed it on your own website because I had it created through university funding and it’s copyright free. So we’re trying to make it really easy but if they answer yes to one or more of those questions the likelihood is is that they’ve probably got at least some TMD.
Then the question is, what does your examination tell you? Does your examination tell you that it’s attributable to the pain that they’re complaining about, that they’ve come to see you about essentially?
[Emma]
I think your specific question is, do you give 3QTMD to every single pain patient that comes through the door? And as Justin said, it would be a no. If you are hearing and you think it may be TMD, it would probably quite be quite a valuable addition because it could give you more clinical confidence moving forward to get and kind of probe and maybe focus your examination on TMD.
So 3QD at TMD. It’s great for those that we think has got TMD and from a general dental practitioner’s perspective, it’s really good for people who aren’t that confident in TMD diagnosis because it can be like, oh, okay, I’m going to ask those three questions. There was yes to one of those questions. So I need to look more at TMD. I’m going to examine in more detail, the joint and the muscles. So that’s where it’s probably it’s most beneficial.
[Jaz]
Recently I did a talk and I compared the 3QTMD to, it’s like doing a BPE, but for the TMD. And the general dentist seemed to like, no, okay, that’s just, it’s like a screening tool basically. And they seem to understand that. Do you like that comparison?
[Justin]
I’m going to steal that now. Gulati et al. 2024.
[Jaz]
Excellent. Now, the reason I want to go down this approach is because sometimes I’ve seen a patient being referred to me for a wisdom tooth issue, but actually my correct diagnosis ended up being a painful TMD and I’ve had it the other way where I’ve had a clinician referred to me for TMD, but actually it was a cracked wisdom tooth.
It was a cracked molar. So there is a bit of overlap, which is why we need to do more probing in the history and examination. Where do you think is a good place to learn the skills of examining, like for example, you’ve got some images in the guideline for palpating the muscles, how to do bimanual manipulation, and you’ve got some images there that I saw.
There’s also on the RDC website, I believe a long time ago, I saw they got like a full video there of how to check each muscle. My worry is for the general dentists who may not have as much time. For example, when I see a TMD patient, I have 75 minutes allocated to me in primary care, which is a lot more than what some colleagues may have in general care.
I guess I’m trying to ask is what advice could you give to clinicians who are working in the busy practice to be able to get some more skills for the actual examination of the muscles, if you like and the joint.
[Justin]
Firstly, you’ve got nearly double the amount of time that we have in secondary care. So you’re an incredibly lucky man for 75 minutes. But yeah, I agree. We work on between 30 to 40 minutes for a facial pain patient, be it TMD or a different type. I think we’re about to, as I say, launch that campaign. And with that campaign comes a QR code that does a standardized exam in a simple way for general practice.
And we can give you the QR code for that ahead of that because there’s no state secret and it’s a very brief version of the RDC video that you saw many years ago, because we’ve just finished publishing a brief DC TMD. So brief diagnostic criteria for TMD that was aimed at the general dental practitioner.
We work with general dental practitioner colleagues nationally and internationally to try and do that. So we’ve got a version of that that we can share. And I think that would be the simplest thing, but I mean, a standard extra oral exam involves the examination of temporalis masseter, which are the only two muscles that international recommendations would suggest.
So you don’t need to bother with lateral pterygoid because you’ve got to be a, have a bit of a strange finger to reach it. Firstly, up and around the back of the tuberosity and not evoke kind of vomit on your shoes and medial pterygoid similarly, it’s not a very nice place to have palpated. And actually the vast majority of the diagnoses have been made with pressing on masseter and pressing on temporalis.
So you don’t need to bother with any of the digastric or any of the suprahyoids, et cetera. So it is a lot simpler. And I think, again, it’s about demystifying. Cause you know, years ago when I was taught, which was a good 10, 15 years ahead of Emma, we were taught about digastric, medial pterygoid, lateral pterygoid, even getting down to trapezius.
You don’t need any of that. You need masseter and temporalis. Make it easy. That’s what you need to do. And then you need to look at the jaw movements in three directions, three times. So forward and back, open and closed, side to side, three times each, one noise means you’ve made a noise. You can record that the noise is there. So one out of three movements with a noise, that noise is present. If you hear it or the patient hears it and you only need three movements, that’s what it says. Three movements times three.
[Emma]
Yeah, I think that’s a really important thing that Justin said about just masseter and temporalis. That’s it. Two muscles and then jaw opening. That’s the jaw movements and they can be done. I think the video that Justin is talking about, I think when we recorded it, it was 1 minute 41 seconds was our entire examination for TMD, which was the muscles, the jaw movements. And I think I might be wrong, correct me if I’m wrong, Justin, you also had facial and trigeminal nerve in there just in case. So it’s kind of a very short, I think I can’t remember, but it’s very short.
[Justin]
That was very quick if I did.
[Emma]
It’s very quick, but you’re right there. It’s about giving people the confidence that that’s enough to do. So the temporalis and masseter, if you’ve got any of the other muscles are sore, the evidence shows that temporalis and masseter will be sore.
If temporalis and masseter are, which is why you don’t need to then do the extra ones. And the other thing to add to when you’re doing the examination, Justin and I both routinely ask two simple questions. We’ll be feeling the muscle and we’ll say to the patient, does that feel sore? It’s a yes or no answer.
Yes or no. If it doesn’t feel sore, there’s not a muscular pain in that muscle. Okay. So it’s not a myogenous TMD in that muscle. If it’s a yes, the second important question is, does it feel like the pain you are complaining of? And what we’re trying to work out there is familiarity. So familiarity of pain means that a positive diagnosis means that you’re targeting the patient’s complaint.
So as an example for that, I’ve got myogenous TMD, exactly the same as Justin has. So when I palpate my masseter, I would say yes. And when, just if you guys examine me, I would say, yeah, that is the pain I’m complaining of. You mentioned earlier that you might have the co referral where they’ve come to you for an eight.
And so you might get somebody who says, yes, it’s sore when you’re feeling my masseter there, but the familiarity wouldn’t be there. It would be no, that doesn’t feel, it’s not eliciting the pain that I’m complaining of. So that’s the key thing. So feel the two muscles. Feel the jaw joints. Do the movements Justin’s talking about, and specifically ask, do you have pain? Is this the pain you’re complaining of? And that, that then easily just ticks. You’re either a TMD side or you’re not a TMD.
[Justin]
The other thing that people often ask is how hard do I feel? Am I pressing too hard? And the answer to that is, is you press on your own kind of thumb area and I’ll do it on camera. But if you press on your own thumb area and you think your nail blanches, that’s about the right pressure. So if you read up on capillary refill time. That’s kind of the sort of pressure that you’re after, but generally speaking, if your fingernail is blanching, that’s as, that’s as firm as you’re going to go. And that’s probably a tiny bit too firm as well, but actually you’ll only get a positive response if there is actually muscular pain and tenderness thing.
[Jaz]
I think it’s very reassuring. I mean, if you had the luxury of time, like I do, I, yes, I do a few more things. Some for certain individuals, I might get into sternocleidomastoid, but what I wanted to break down today is really make it tangible for the general dentist who’s almost like feeling fearful about examining the masseter and temporalis just to give them confidence that you’re doing enough.
And even just for advocate for general checkups, just feel the contractions, okay, because you can learn so much about a patient’s occlusion based on, are they synchronous in terms of how, when they contract, has someone got really large hypertrophic muscles, high bite force, low bite force, we get so much information and the more you do it, the more confidence it will give you is that when you need to assess for a pain type condition and that wonderful question that Emma mentioned about familiarity, which is really, really important in our diagnoses.
When you have that scenario whereby and just going off the flow chart a little bit here. The whole thing about acute pain and how it can be a little bit difficult for a patient, for a dentist to manage acute TMD pain. According to your flowchart, there are some things that we could do in that acute scenario when you have limited opening, right?
So if a patient comes in, emergency, they’ve got limited opening, you’ve done your assessment, it’s familiar pain, and you can see that they cannot open their mouth very big. First, we’ll start with how many millimeters do we start to worry about and categorize it in terms of acute limited opening?
[Justin]
Probably about 10.
[Emma]
Yeah, it’s a really good.
[Justin]
Go on, Emma, after you.
[Emma]
It’s a really good question and I think we haven’t really helped ourselves in the previous. So anything as an unassisted opening, which is passive opening by a patient, so that just when you ask them to open to where they feel comfortable, anything less than 35 millimetres is restriction.
For the acute restricted opening, anything 10 millimetres or less. So if they can’t get a finger between their teeth, that’s the ones we’re kind of more worried about from an acute restricted opening. Does that fit with what you were going to say? Sorry.
[Justin]
Yeah, yeah. But it’s got to be their own finger, not your finger. Because everyone’s fingers vary, and I think that is the key bit. Because there are no good data on normal mouth opening, it can vary between 35 to 50 mils, depending on height, weight, build, culture, ethnic group, you name it. It can vary all sorts of ways, in the same way as hair pattern can do, eye pattern can do, etc.
So yeah, I think one finger breadth is where we get more concerned that there’s something very acute going on, and then look for the red flags, and then is it the muscle, or is it the joint? And that’s the question to ask yourself is the limitation from the muscle or from the joint?
[Jaz]
Can you give us more diagnostic clarity in terms of determine, is it more muscle, is it a joint? Only because in the guideline that we’re looking at, it says if you think it’s limited opening, like you said now, about 10 millimeters or so, due to a muscular origin. We’re looking at potentially diazepam, whereas if it’s more a intracapsular arthrogenous issue, something to do with the disc, something to do with the cartilage, something to do with the joint anatomy itself and not the muscles. We’re looking at steroid, oral prednisolone. So how can we make that distinction? It’s quite difficult when they have that limited opening.
[Emma]
Yeah, well, okay. I think this is actually a really important conversation to have because it’s really interesting to hear that that’s how the guidelines reading. So what we’re saying is if someone comes in with an acute TMD and they’ve got significant pain, whether it’s alphagenous or myogenous, we would want you to rule out red flags, diagnose, deliver supported self management and in a severe acute pain, you will probably be advising routine over the counter analgesics as a first line.
There are a very small number of patients who may come in, in very significant distress. And for those people, you will probably be at that appointment, giving them a referral to secondary care straight away. But then, in the short term, in addition to that basic things we’ve talked about that probably everybody should have for an acute TMD.
The myogenous ones where they’re, maybe it’s so severe that they can’t maintain their nutrition. So they’re telling you, I can’t eat, it’s so bad. You might consider diazepam. To just give you a little nod to how often this is used. I think I’ve prescribed it once ever. And I’m trying to work out now. I graduated in 2008 and just in. Can probably give you an indication of how many times he’s used it, which is probably either zero or once as well, Justin.
[Justin]
Yeah, probably three or four. And I’ve been practicing since 2000, but then in my practice is skewed. So I think we need to be careful to say that, we’re not on the front line. They might meet Jaz first and then Jaz would refer to us and things might be better. So I think it is a difficult one and just to pick up on something else. So Emma’s quite right. You said start with over the counter analgesia, non steroidal anti inflammatory three to four times a day, as you would advise, if it was a wisdom tooth, problem or what have you, and then paracetamol a gram four times a day on top of that.
First of all, stepped, but if stepped, i. e. you do the ibuprofen, breakfast, lunch and tea, paracetamol in between, if that isn’t cutting it, then the Cochrane review would suggest that if you have the ibuprofen with the paracetamol, you’ll get an uplift in the pain relief that you would get. But also added to that, look at the self management guidelines on using covered ice and moist heat, because that will help with both muscle and joint issues.
And I think you asked, how do you know whether it’s muscle or joint? Again, goes back down to history. So if you’ve got a click, and you had a click before this all happened, and the click has suddenly disappeared, the pain’s extremely located and familiar in front of the ear, directly in front of the ear, and when they open, they’re deviating towards that same side, then that sounds very like a joint issue.
A bit like it would do if they’d fallen over and traumatized their jaw joint and broken their jaw joint. It would deviate towards that side because the jaw will hinge and slide on the unaffected side, which means the chin will move over to the affected side. points in the right direction and their mouth opening will definitely be less than 15 mil and it will be really, really uncomfortable because they’re basically functioning on a piece of sensory tissue at the back of the disc.
When that’s happened as a muscle, generally speaking, they can get down to 10 mil, 15 mil, but they’re really severe if that’s the case, they normally have a little bit more give, and sometimes if you try very gently to stretch them, you’ll feel that it does feel like it will go a little bit further, whereas if you try and stretch it.
A mouth opening that is, that’s limited by, say, the articular disc being out of position. It will feel like you’re trying to push a door against a door jam on the other side, or a door stop on the other side. It won’t give at all. Whereas the muscle one will feel like you’re probably pushing against the door with someone who’s not as strong as you, the other side.
But if you’re going to try and stretch those jaws, it must be in patients who haven’t had a recent history of trauma. If they’ve had a recent history of trauma, do not stretch mouth opening because it’s more likely that they’ve got a fracture or an issue. And if you’re going to stretch mouth opening in people who haven’t got a history of trauma, make sure you say to them, I just want to have a very gentle feel of what this feels like.
I’m not going to do too much. It just tells me roughly where the problem might be to help me guide what I tell you. So they’re kind of, it’s flagged and you won’t need to do more than like literally a second or so, because you’ll feel if it’s a disc problem, it will feel weird. You are not going to move those teeth further apart.
[Jaz]
Some terms I’m going to just use, Emma, is hard end feel and soft end feel. That’s what you’re referring to, right, as a physiotherapist. Yeah, fine. So just for those who are just marrying it together in terms of some, where they might have previously read it. Yes, Emma, please.
[Emma]
Yes, I was literally just going to bring that in because if you’re thinking about the pathogenesis, so what is causing the restricted mouth opening? In a myogenous TMD, it’s basically guarding. So the body is trying to resist movement to protect the area to allow healing. So the muscles can move, but they’re trying not to, which is why when you have a gentle stretch, the patient might passively open to that 10, 15 millimeters. But you, as a clinician, when you try to stretch them that little bit further, you will get a degree of give and it feels softer.
If you think about what’s causing an arthrogenous restricted opening, the most commonly is the disc displacement without reduction, which as Justin said, the disc is completely in the way of movement. The disc is cartilaged, so it’s hard. So when you try to stretch, you just can’t get that difference.
So that’s what I was just going to give it, bring in there. And then with the adjuncts for acute, if they’re really struggling, if we think about the theory behind the diazepam. So diazepam is an anxiolytic, it’s a sedative, but it’s also a muscle relaxant. So from the myogenous TMD that are really acutely guarding and really restricting movement, people really struggling with function and eating the short course of diazepam at a very low dose in a very controlled way might help that muscular issue.
And when I say in a controlled way, what we say in the guidelines is that we would advise two milligrams, so a tiny dose, three times a day for just five days. On day five, you should review. If it’s having a positive effect, then you can stop there. If it’s doing something and you’re getting some sort of benefit, but it’s not quite where you’d want to be, you could then consider it for a maximum of a two week in total, but only if you’ve had that review. If it’s not done anything at all, it’s not helping the patient at that day five. So don’t keep it going.
There are a lot of contraindications for diazepam. So there are a lot of patients where it’s not appropriate to prescribe it. They’re all in the BNF. There’s would be no surprises there. So people with dependency issues, people, it causes respiratory depression. So any kind of respiratory issues, people with issues with liver or kidney function, and so that people would be looking those up as per normal prescribing practice.
But if you think about why you might be using it, you’ve got really sore muscles. They’re really tight. You’re giving a low dose tiny course of a muscle relaxant to see if that helps them get over the acute phase. At the same time, you’re telling them to use ice that reduces inflammation, put heat on that increases blood flow to the area, helps facilitate healing.
You’re telling them to use analgesics, the paracetamol, telling them to gently massage. So on top of just having that relaxation from the diazepam, they’re also doing the self care really positively. You might just get them over that really, really difficult period where it is agony and it affects anything that gives us joy.
So they can’t talk, they can’t eat, they can’t kiss their partner, they can’t lay down on the area where it goes to sleep. So it just gets them over that hurdle where the impact’s really high. Do you have any questions to ask about that, Jaz? Is that clear from that myogenous adjunct? Are you happy with that for the muscular TMD?
[Jaz]
Yes. That helps a lot, especially the distinction between the two, which I think a lot of people would be wondering about. And that gives a bit more clarity on that. And also just to know that although it’s there in the guidelines and you took that feedback on board that when I look at the guidelines, my eye gets drawn to the red flag, which is great.
We want that, but then it’s almost like in green and like, it’s almost perhaps overplayed that the whole That’s why I wanted to ask you about it, because it’s not something I’ve prescribed before. Diazepam or prednisolone. And so it’s there occupying quite a big space on that. It was something to talk about.
[Emma]
Yeah, you’re right. And it’s a good point, Jaz. It’s something to think about. What we write isn’t necessarily taken on. It was not necessarily seen how we’d like it. And this is how they always develop, always develop.
[Justin]
The whole document is about to be typeset because that’s the in press version. So we can actually adjust that in the final version because the college will. Like typeset it in their own way so you can take that on board because I don’t want people to feel that they’ve got to go out and prescribe diazepam or prednisolone. It’s there because it is an option in the acute option.
And again, if you were in general practice and you’ve got a good working relationship with general medical practitioners around you, I know for some people, specifically in rural settings, they’ve got really good working relationships with a general medical practitioner because they have to get the INR testing, or what have you done in that general medical practitioner, you could have a conversation with the patient’s general medical practitioner, explain your diagnosis and say, I think, the guidance says this, would you be happy to prescribe this?
Because I’m not, it’s not something that’s normally prescribed by me. And they would give you a straight answer one way or the other. And most of them are extremely amenable people because they want to help as well and the patient might call on them after you anyway. So you might be heading that off to say, I’ve had a conversation with patient. I think it’s a TMD. I think it’s this acute version. I think they might benefit from some diazepam. Would you be happy with that?
[Emma]
It’s in the clinical knowledge summary for GPs. It’s the diazepam. So yeah, that’s a good point to stem.
[Justin]
The clinical summary for people who aren’t aware is, is it sort of a nice accredited repository of information that GPs quite regularly use. Cause understandably, like general dental practitioners, they have to be master or mistress of everything that they sedate. And sometimes you need to refresh your memory. Cause I certainly do. And I only have a smaller subset of things to deal with rather than everything and anything that can walk through the door.
So it’s actually quite a good resource if colleagues haven’t seen it for dentists as well. It’s called, you basically Google NICE clinical knowledge summaries or CKS for short. And it’s got a good section on TMD that’s been updated in collaboration with ourselves. And it’s actually quite a good resource for all sorts of things.
[Jaz]
Emma, I think you wanted to say something.
[Emma]
So I was just going to move on to the adjunct that’s mentioned for the arthrogynous TMD in the form of an oral corticosteroid. So in the pop out on the guidelines, we talk about you could use prednisolone orally.
Again, a short six day course of 20 milligrams once daily. The theory behind that is that if you’ve got an acute disc displacement without reduction, as Justin says, what that means is that the disc is usually pulled very far forward in front of the condylar head. The reason why that’s so acutely painful is that all of the tissue behind the disc that it’s tethered to has got all the vasculature and all the nerves.
And what you’re then doing is it’s that tissue that your joint is working on. So as the condyle moves and opens, it’s functioning on that tissue instead of the nice chunky cartilage that doesn’t have the pain that doesn’t have the nerves and all the blood supply in it. So that’s why it’s so painful.
And so the reason why prednisolone might be beneficial in those cases is because prednisolone is really anti inflammatory and so it’ll just calm everything down within the capsule of the jaw joint. Again, I’ve never used this but they come to us later. The evidence is in only for a disc displacement without reduction.
So they would have had a history usually of clicking and then what we would call a closed lock. So they’ll come in and they’ll say, I cannot open my jaw. When you try to stretch it, you cannot get any give, and it’s kind of a really firm locked jaw. So there is some evidence that that might be beneficial.
Again, same as for diazepam, you have to look at who it’s appropriate to prescribe it to, who it’s not appropriate to prescribe it to. You would be doing it for a short course only, so a six day maximum, and reviewing. It wouldn’t be one even at review, if you’ve had a benefit, you wouldn’t be continuing it for a longer period.
[Jaz]
Like I said, it’s really good to know about the fact that it’s not something that we’d be expecting to prescribe a lot, but in those acute scenarios that you’ve described, it can be very helpful. You’ve also written here about stabilization splint for those very acute scenarios for disc displacement without reduction. Now stabilization splint just to for everyone is I believe you mean any sort of splint that just gives you even bilateral contact that covers all the teeth, right? Do you make a distinction between hard and soft when you say in the guideline here, stabilization split, and exactly who is the ideal candidate here?
Because obviously when this very extreme restriction, like you’ve said here, the muscular or joint related, then you’ve said diazepam prednisone may have a role in those very few patients. But where do you see the guidelines in terms of the rationale behind the stabilization splint at this acute stage, obviously in conjunction, by the way, with the supported self care, right?
That which is a whole fantastic area, which you’ve got the patient guidelines, well, the QR code, the videos that they can use, which we’re going to make available, everyone should use those. So everything is on that foundation that was mentioned. So that’s really, really important to just highlight again, but tell me more about the stabilization split here.
[Emma]
I’ll let Justin jump to stabilization splint. But I suppose one thing to be really wary of is the ones that we’re talking about here with really acute trismus or restricted opening, you won’t. be able to get a stabilization has been probably in their acute period because they haven’t got the opening for the IMPS or I’m afraid we’re a little bit behind the times. We don’t have an intraoral scanner yet, but I believe you’d still have to have a significant degree of opening to get an intraoral scanning done to make your splint.
[Jaz]
What I find so far is that 26 millimeters is what I need to get my iTero scanner head in. Okay. Anything less than 26 millimeters. I can’t do it. Even then it’s like regular breaks and stuff. So, and that’s what the ITO is quite a thick one. Maybe you can get a little bit lower, but yeah, you need a mouth opening that’s sufficient for either way, whether analog or digital.
[Justin]
Do you have to say other scanners are available or? Is it specifically iTero that we need to use?
[Jaz]
Something like that. It’s just the one I use.
[Emma]
Yeah. So for these with, you’d have to get enough opening to allow a splint, but then I’ll let Justin pass on to what types of splint we use and why they might, what they might be good for.
[Justin]
Yeah. I mean, I think the splints are one of those things that have been around for eons and they’ve got all sorts of different pieces of evidence about them. Some positive, some equivocal, i. e. they can’t really tell whether they’re useful or not. I think you’ve already stressed Jaz and we don’t need to go on about it. ad nauseam, self supported management, support self management is the most important thing to start with. If the patient isn’t getting on well with that, then you can consider an adjunct to the splint.
Simply put, back to Ed Trulove’s study in 2006, which was a good quality study, you do the simplest splint that you can do in the quickest possible time. So he found very little difference between what we colloquialize as a lower soft splint, so a polyvinyl suck down, sometimes called bite raising appliance that covers all of the teeth.
He found very little difference between that and a stabilization splint, which generally is meant as a Michigan or a Tanner splint. So it was cold cure acrylic. Opened to say three, four millimeters increase in occlusal vertical dimension, they talk about having it in RCP, retruded contact position, and they talk about having even contacts across the occlusion and canine guidance.
The actual answer to that is if you read Ed Wright’s work, he was a retired USA Air Force dentist who specialized in TMD, he quite clearly. explains that not everyone needs to be in RCP and not everyone needs canine guidance group function. If they’ve already got group function is fine. What they need is smooth and easy movement across the occlusal plane.
And essentially a splint of any variety is a bumper or a buffer or a bandage or a crutch in the sense of nursing an injured leg to try and help take some of the pressure off the tissues, put a little bit of occlusal vertical dimension in so your teeth are apart. The muscles are not therefore contracted.
You’re not loading the joint, perhaps as you would do if you didn’t have the splint in. And that’s essentially their role in this. People do worry that they become a kind of psychological crutch, and people become very attached to them. I’m not convinced by that argument, I think the argument is, is that the evidence base is not good enough to say that you should spend money as a patient on getting that as first line.
It’s a second line, a jump to treatment when you’ve tried some supported self management. If you gave it alongside some supported self management, I wouldn’t say you’re doing anything wrong there. I think that’s perfectly reasonable. What I would say is really inadvisable is just to give a patient a splint and say, that’ll help you off your pop because they don’t know why it will help them.
They don’t know why they would use it. And some people just don’t tolerate them. Well, some people have a soft splint and they tell you they grind or clench more on it. And I think that is the case. And if they tell you that, believe them and they might be the people who might benefit from having a hard cold cure or bilaminate type splint created.
And I think you just have to take the patient on the journey with you and explain to them that these work for quite a lot of people but we’re never quite sure how they work or who they work in, but they’re quite simple, they’re quite non invasive. As long as they’re full coverage, and that’s the critical thing, then you’re going to see very few adverse effects with them, assuming that the patient’s periodontal health is good as well, and they haven’t got rampant caries, etc.
[Jaz]
I’ve got Dr Wright’s book actually, I believe, it’s a yellow cover one, I think, and in that is a whole section on stabilizer, yes, very good book, Stabilization Splint, and what I like about that is, just like you said, you have to make it accessible and easy for the dentist to do so that they can get good care quickly or get this, this type of care and quickly because if we then focus on we’ve got to get the face bow and we’ve got to get this and make it high precision.
That’s a completely different type of this. That’s not pain management, pain management is get something in that gives them bilateral even contact, something nice and smooth for that acute management. And I’m glad that you’re echoing that as well. Cause a lot of clinicians, they think that, oh, I don’t have the means or I don’t have the skill or the precision to deliver a stabilization splint.
That’s not true. You can just get something in that covers all the teeth and gives them some balance. And that acute scenario. As an adjunct to support to self care is the way to go rather than worrying about canine guidance and all those features that you read about.
[Justin]
Full coverage, simple as you want it to be as long as the patient understands what you’re trying to do and as long as you’ve done the sensible things that you would always do as a dental professional.
[Emma]
I think as well, we would always rather people feel comfortable with what they’re providing and provide that well. And I’m thinking here, the example of a good lower soft splint, rather than them providing an upper stabilization splint that is worse because they don’t know what they’re doing. It’s different for everybody.
A stabilization splint will last longer for the patient simply because it’s a harder material. So they might need to replace it less often. It takes slightly longer to fit, but there are good courses that can help you with learning how to do that skill. And then it’s just something that’s in your armamentarium should you need it, but do what you feel comfortable with. Maybe Justin and I need to do a course on splints and how to fit.
[Justin]
I think Jaz runs one, don’t you?
[Emma]
Do you? Oh, Jaz, welcome to Jaz then.
[Jaz]
I do one, but the main thing I want people to take away is the following, whereby, and here’s my bone to pick with oral surgeon, oral surgery departments all over the country and the world, okay? Here’s my bone to pick, and let’s have a bit of a discussion, debate here. Off script, okay?
[Jaz]
Soft splint, okay? I think it has a role in acute management, absolutely, okay? It has a role, but the way that it’s delivered okay. It’s just like, here you go, pop this on. And there’s probably, if you look closely, it’s probably just one or two cusps, cusp tips touching.
That’s not balanced. If you read the Wright’s paper, I think it was in 1992 where they had to N equals 30 basically, but they describe a beautiful protocol of heating the guard and getting the patient to bite into it and to get that nice balance. I personally, I vouch by that. That’s how I teach it.
That’s how I do it. Whereas when you just see a soft splint and they’re just bouncing on one side, the muscles are all over the place. That’s not giving them bilateral contact, but no one ever speaks about that. Is this something that you guys do? Why don’t you, if you don’t do it, I would love to know.
[Emma]
Yeah, well, we actually on the guideline group, we had some really fabulous restorative dentists who had pretty similar opinions to what you’ve just shared on along the lines of a soft splint is a less predictable, less stable, because even if you do that and you heat it and you get them to bite, so you’ve got nice, even contacts, they’re going to wear through it a little bit more, maybe in one area and then another on a soft splint.
So that isn’t a longitudinal consistent relationship. And so what I would say is in our unit as a general rule, we use a stabilization splint. But that’s because we feel comfortable fitting them. So we’re talking about the hard acrylic splints then. We feel comfortable fitting them. We feel they last longer.
We feel it’s more predictable. But what we’re saying is in the evidence, there hasn’t been shown to be more benefit from one type of splint than the other. So a general dental practitioner should use what they feel comfy with. What do you think Justin?
[Jaz]
Yes, please. And then also just give some guidelines for those listening who want to do a stabilisation split. Now, yeah, again, in your guidelines, you have a link to, I believe it’s a dental update paper, which is very good of you to link it. And it shows you exactly how to make a well fitting one.
Again, my bone to pick with that paper would be, it’s a little bit for acute management of pain, it is a bit too restorative-y, it’s a bit too care and guidance, perfect, facebow, and that’ll be my criticism for what we’re trying to achieve in pain management, but it’s good to aspire to that, and to know the lab side and the ins and outs of it, it’s absolutely good to aspire to that, but I’d like to know how you do it in your limited time that you have in your pain centered clinic, and what advice would you give to general dentists to help make one that is a bit more real world friendly?
[Justin]
Well, I think one of the things that we did miss was beauty hard wax, cause it stopped because we used to love a bit of beauty hard wax. It shows you how old and traditional we are. And they binned that because that was one of the easiest ways to get the registration right for a position approaching RCP.
We would simply use, because we’re not digitally enabled as yet. We would simply dry off the arches and do really good quality alginates upper and lower. We would have then previously ask the patient to get into a position approaching RCP, so we would guide them in. We wouldn’t force them in. It’s not kind of like trying to get them right to the back of the space of the glenoid fossa.
It’s where they feel comfortable. And it might be that that’s only like a smidgen away from ICP. And I’m not particularly precious about that. And if you read Ed Wright’s work again, he’s done the work, he’s done the research. And he says, that’s normal, that’s very different to if you’re doing a occlusal rehabilitation for a different type of patient for a complex restorative procedure.
You need to be in RCP because it’s reproducible. That’s not what we’re doing here. So I would get them into a position where they think that feels comfortable. I talked to them about, think of your jaw a bit like a gear stick. When you’re in gear, it’s working. When you’re out of gear and in neutral, it’s not working.
And I tend to sort of show them, this is my teeth together. That’s ICP. That’s where you can see my muscles bulge. That’s me in gear. When I’m in RCP, this is how my jaw looks. It hangs loose and that’s what the neutral position is that we’re trying to get you to. So then I’d guide them into that a couple of times and then I would literally take a leaf gauge, something between 20 to 25 leaves depending on how deep the overbite is and then blue moose, either side, ask the cast to be articulated up on that position.
And then we use biolamina now, which I have to say are a damn sight easier than cold cure, well, the old flask and pack, pack and flask, I forget which way around it goes, it’s so old now. And because they just got a bit of give in them, they’re more comfortable for the patient, are actually easier to adjust as well, because there is a bit of give whereas cold cure, getting it to fit across the arch could have been a bit of a work of art.
And Emma and I were the people who did most of those, I think, five, 10 years ago. And they were really challenging. So I think with the bi laminar type. Approach now where there’s a hard surface on the occlusal surface, but a soft surface on the fitting surface to the teeth and the gingiva.
They’re much easier to fit and create. And I think they’re easier for labs as well, because they can almost do the initial base work if they are, if it isn’t digital, just using a suck down approach from my understanding of their techniques. And then we would just see them to fit them and look for even occlusal contact and a smooth guidance, rather than a guidance where they’re actually having to make a big movement, like a down and out movement, we just wanted you to slide around nice and easy. Imagine a bit like being on a skating rink and just being able to slide around really easily on that without big movements.
[Emma]
Yeah, the RCP registration is the thing that probably GDPs want most guidance on because all of them will be happy, I would assume, taking an upper and lower alginate impression. It’s about how do you capture the jaw relationship. And so they basically need something between the front teeth to give them some space. And they need the mandible a little bit further backwards. So they could use a cotton wool roll if they don’t have a leaf gauge. They could perhaps use a softer wax.
We, we loved Beauty Hard Wax because it didn’t give us much, but they could perhaps use a softer piece of wax once they’ve almost got the patient to open. Place the tongue on the posterior aspect of the soft palate and then guided closure with both of the dentist’s thumbs on the chin. It’s shown if you do it with just one thumb, you can actually push it to one side or the other.
So both thumbs on the chin, just to guide it slightly posteriorly helped by that tongue positioning. And then you need something between the front teeth to just keep them at that point. So it could be a cotton wool roll that probably is a little bit too wide. It could be something like folded gauze. It could be some wax.
[Jaz]
You can use also some bite registration material anteriorly. Once you found them, let it set on there.
[Emma]
Gorgeous. Actually, that’s a good idea. Like a harder, a quicker setting putty, maybe anteriorly, and then a softer silicone to then pipe between the occlusal surfaces. And that is enough. So almost upper and lower alginate imps, gently guide them into ICP. Something anteriorly to hold it. And so you can get the squirt of silicon in. That’s what you’re looking for. You don’t need to overthink it. I hate face bows. I haven’t used them for ages. I was never good at using them. You don’t need it as much for pain.
[Jaz]
I love this real world discussion, which is exactly what we need because you want to make this guidelines implementable. I’m not saying that we need to be taking shortcuts, but what we know, just like you said, Justin, is that there’s no evidence say that this is better or that technique’s better. And what we need to do in pain patients is just reset, go into neutral, get that nice, smooth sort of ice rink analogy that you use is absolutely brilliant.
And in the interest of time, I mean, I’m going to say it in my intro, and I’m going to put a few ads in there just for them to download these guidelines. They’re absolutely brilliant. It’s got the whole supported self care manual in there for six to eight weeks. It describes everything. It just needs for dentists to do their due diligence.
And then what happens if they don’t respond? What happens if they respond favorably maintenance? What happens if they get a little bit of response? It’s all in there, including the physiotherapy role. And so there’s so much, I mean, you could easily talk eight hours, right? Easy go eight hours, right? Spend a whole day discussing every aspect, facet of it, but that’s not what we’re here for.
We’re here just to raise awareness, firstly, and to have those real world conversations like we did about the splints at the end, and about actually maybe we don’t need to be looking at diazepam, prednisone, do the basic stuff first before you think about that, and in which cases those severe cases may warrant referral, which again is covered really well in the guidelines. While you have the microphone on the stage, just a couple, a minute each. Anything else you want to pass on to our colleagues listening and watching?
[Emma]
I think put yourself in the patient’s shoes. I think sometimes it’s really hard, isn’t it? You need to listen to what they’re telling you is driving their TMD. So a one size fits all doesn’t work. So as an example, I’ve got TMD. Mine’s really bad when I’m stressed and people will tell you things that are giving you information on what might be precipitants for their pain that we’re not hearing. So for me, I get it about three times a year. Usually when I’m stressed, it’s a myogenous TMD.
So for me, the splint does less. For me, what works better is understanding my triggers, managing my stress, sleeping well, and then doing things like massage at the time when it’s at its worst. For other people, there may be, for example, a more kind of biological drive. So maybe the people who say my TMD is at its worst after I’ve talked all the way through the day, all day, it builds up, it peaks in an evening, and then I struggle to get to sleep.
[Jaz]
Teachers, my teachers, TMD patients are exactly that.
[Emma]
Yeah, exactly that, rather than the other way around. So for them, it’s about breaking that cycle of use throughout the day. So can they, perhaps they’re, in addition to their talking, they’re also clenching. So we do a lot of behavioral management. We tell them to put a spot on something that they look at.
All the time throughout the day. So watch, phone, computer screen, teachers, they might just put it on their desk. Every time they look at it, it’s a behavioral reminder to relax, reduce clenching and just make sure everything’s in a neutral position. And then for those people wearing a splint on the nighttime, through the night as they sleep might just allow them to just get the balance a bit better throughout the day.
So listen to your patients and target their needs, but also talk to them about why you, make the decisions together. So, this is what you’re telling me. You’re telling me that it’s worse at these times, so how can we make it better at those times? And you just fit the jigsaw puzzle to them, rather than just throwing a splint at everybody, or maybe telling everybody to massage their muscles, whereas actually there’ll be some people where it’s more beneficial and less beneficial.
[Emma]
Target the patient.
[Justin]
Yeah. I mean, I think probably a lot of what Emma said already, which is, TMD when it first presents is. It’s quite simple. Don’t let people overcomplicate it for you. It’s simple. You don’t need a splint in every case, but you do need self management in every case.
And as Emma says, it needs to be targeted to what the patient’s experiencing and what the patient can do in the time that they have available. And it isn’t simple in its etiology. So it’s not just about grinding or clenching or the bite, so don’t try and oversimplify the etiology. The etiology is quite complex, but what we know is is the management of it isn’t in the vast majority of people, and you can start that as a generalist, and you can start it in an evidence based way that your patients will probably get on very well with, and just don’t be frightened of it, and don’t let people overcomplicate it to you.
Again, that’s not to say that we don’t see some really complicated cases, but they are a small minority and we see them because we have a sort of sieve because we’re the people with the special interests in it. The vast majority that will come in through the door will be very straightforward things that you can manage in primary care and can be supported in managing in primary care by people who’ve got specialist interests as well.
[Emma]
Yeah, can I add one thing? Because I think we work with wonderful pain psychologist, Dr. Chris Penlington and what she really positively does with our undergraduate students is explains that your relationship as the clinician with the patient can have a huge effect on their pain experience. And so what we mean by that is if people don’t feel listened to, don’t feel validated, don’t feel like.
We’re picking up on that specific problem. It can actually make their pain worse. And so we’ve said to try and reassure GDPs that temporomandibular disorder is simple. It is, I would never say that to my patient because for them who can’t eat, can’t talk, can’t sleep, it isn’t simple and that would devalue their symptoms.
So give them time. Sometimes, overrunning by 10 minutes to, to allow someone to feel heard, to be really clearly explained to them why they’re getting their problem can be what they need to get over the hurdle. Jaz, you said you get lots of referrals and I bet you’ve heard it the same as Justin as I. I’ve been to so many different dentists and they can’t fix my pain.
And then when you ask them what they’ve been told to do, they’ve been told to massage, do jaw exercises and analgesics which are the right things. But if you say to me, I’m in agony and it’s really hurting. I say, you’ve got a problem with your muscle. You need to take some painkillers and do these exercises.
It sounds like a fob off. If I say to you, the reason muscular TMD is so painful is because the body aggressively protects the head and neck region. I often say we can’t rest our jaw. It’s like if you have the sprained ankle and kept hopping on it over and over and over again. That’s why the pain gets so bad.
What we need to do to try and break the cycle of these things. Use heat, it brings blood to the area, it calms it all down. Use ice, it reduces inflammation. Massaging the muscle causes relaxation. It reduces muscular guarding. It eases the tension. And then take analgesics. I’ve told them the same information as the first example.
I’ve given the same instructions but the patient might feel more heard and I think maybe, what you’ve just pointed out in the guidelines is that big green box, it maybe pops out in a way that’s different. If that makes sense, it’s been read in a different way to what we thought it would be.
Whereas that, so actually being aware of what you’re saying and how it’s interpreted is very important. And Justin and I will often say to the patient. What do you, at the beginning, this is your pain history and I’ll be like, okay, what would you like at the end of this consultation? And they’ll often say, I want to be 100% pain free, or they might say, I want to know what causes the condition.
But by asking maybe that one question, giving them a little bit more information on why you’re telling them about the supported self management, how it can be effective. All of a sudden, it’s given them ownership. They’ve been listened to. They’ve got the tools to make the difference. And I think that’s the important thing.
[Jaz]
What a wonderful contribution there. And alongside the fantastic guidelines, everything, I really appreciate you adding the extra couple of minutes. That was really a wonderful summary. I always say that when communicating with patients especially in a field like TMD where I get patients who’ve had every spin under the sun and tried all sorts, basically, if I’m suggesting something, I want to show them my working out.
I just want to recommend, I was like, okay, well, actually, this is what I think is going on because of this factor. And the rationale behind what I’m recommending here is to achieve this effect. If this doesn’t work, then we’ve got a few things, but I think this is a more minimal way of doing it than an aggressive approach, but there’s a pathway.
So I think it’s all the delivery and communication. You summarized it absolutely beautifully. In the interest of time, cause I know you probably got things to do. I’m really sorry to run late, but I really am thankful for you to say, if it wasn’t for this extra 13 minutes, we wouldn’t have extra wonderful tips that you gave that Emma as well.
So thank you so much for the guidelines. Making it freely available to everyone. The amount of hours it would have taken for you all as a team. People will not appreciate, they’ll just consume and digest this, but I can only imagine the sheer, I mean, it took 11 years, right? But all the hours it did as well. So thank you from the community and the profession to you guys. Helping us to better ourselves in TMD management.
[Justin]
Yeah. Thank you for having us on Jaz. It’s really helpful and hopefully people will take notice and have a read and move things forward. So thank you.
[Jaz]
I’m going to shove it down their throats, Justin. Don’t worry. They’re going to listen.
[Justin]
Don’t give him any TMD for God’s sake, Jaz. Whatever you do.
Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. I really appreciate Professor Justin Durham and Mrs. Emma Beecroft giving up their time. I think it’s wonderful what they’re doing to help us spread this knowledge so we can help more patients.
This episode is eligible for CE credits or CPD hours. All you have to do is answer the five questions, get 80% and you’ll get your certificate. If you’re a regular Protrusive listener, you can easily rack up about 40, 45 hours every year, just from the new stuff, let alone the hundreds of hours of the episodes from years gone by.
As well as all the good stuff we put on the Protrusive Guidance platform. You can get that on iOS or Android. The website for that is protrusive.App. And if you’re on a paid plan, you can get your CPD or CE credits. Remember to download all the free resources from this episode. That’s the guidelines that we discuss, the video of me equilibrating a soft bite guard.
And all the goodies relevant to this episode. That’s protrusive.co.uk/tmd. I’ll catch you same time, same place next week. Bye for now. Oh, and by the way, how could I forget? Thank you so much to team Protrusive who keep me sane to keep this podcast alive and going and serving you the Protruserati.
You guys are the best. Bye now.
