How best to help patients with TMD
What tips and strategies can we use when we’re treating patients that come in with TMJ or temporomandibular joint disorders?
After doing a head and neck exam and determining that the patient is having some pops or clicks or sore muscles related to the jaw, then first briefly explain to the patient the anatomy of the temporomandibular joint.
You can explain how there’s a cushion between the lower jaw and the base of the skull, and sometimes as the lower jaw moves open and closed and forward during that movement, that cushion can make a pop or a click that the patient can hear.
Sometimes that cushion can even slip and cause the jaw to lock open if the muscles are really tight and pull on that cushion or the ligaments around the jaw in the cushion are loose. And this cushion can get stuck during jaw movement.
8 tips for helping patients with TMD
There are a few things you tell the patient to try initially.
1.Rest the jaw as much as possible
Rest the jaw as much as possible. That means eat a soft diet. Don’t eat hard crunchy foods, don’t overwork the muscles, don’t chew chewing gum, don’t eat something where you have to open your mouth wide.
Just do everything you can to rest those muscles.
2.Massage to relax muscles
There are exercises you can do to, or there may be massages you can do to massage the muscles of the face and the jaw, but even head and neck and back massage can help relax all of those muscles.
3.Apply heat
We don’t want to put heat and cause more swelling if there is an abscessed tooth with infection, but if we feel like the source of pain is muscular, then we can put some heat to relax those muscles. Warm shower; warm, moist heat, like a washcloth.
Warm water on a washcloth to put on the face; maybe put some dry rice in a sock and put it in the microwave to heat it up and put it on the muscles to help relax it.
4.Anti-inflammatory medication
Four is NSAIDs. Non-steroidal anti-inflammatory drugs like Ibuprofen, Motrin, Advil, Alleve.
Those anti-inflammatory meds are good for pain and to reduce inflammation.
5.An occlusal guard
An occlusal guard is kind of like a pillow between the teeth to help protect the teeth. And a good occlusal guard option is one that goes on the front teeth, an anterior occlusal guard, kind of like an NTI.
There’s certainly a place for an occlusal guard that covers all the teeth. It could be on the upper or the lower, but a lot of times it helps to initially use an anterior night guard or anterior occlusal guard that may go on just the anterior teeth canine to canine or just the incisors.
And typically if you explain to the patient that when they bite hard, it’s easy to put a lot of force on the back teeth.
On those big molars, you put a lot of heavy chewing forces, but on the front teeth it’s hard to bite hard when you put a little bit of pressure.
If you have a carrot, you can bite really hard on the back teeth, but if you bite that carrot with my front teeth pretty quickly, your brain says, whoa, time out. You’re biting too hard. Relax those muscles.
And so if you put that night guard just on the front teeth, then you’re going to protect the teeth with the night guard, because the back teeth won’t be touching, the front teeth will have the cushion, but also it’s going to help relax those muscles because the brain’s going to say, Hey, look, you’re biting too hard.
Relax those muscles. Make the night guard first, especially on the front teeth and let them and see how that’s doing.
Night guards for TMD
Depending on your setup you can make the guard in the office with just an alginate impression or a scan and printing the model and using a drufomat machine to make a night guard, trimming the material to the anterior of the teeth. Only the upper impression was needed for the drufomat.
Alternatively, you can do a chairside NTI or send it out to the lab just to make an NTI or a “B” splint.
When the patient comes back, follow up, see how the patient’s doing with the night guard.
6.Referral to physical therapist
Wait to see how they’re doing with the night guard, but for the long term you may want to give them a referral to a physical therapist who can teach them some home care exercises.
These exercises can empower the patient to do some stretches and things to help relax those muscles and take better care of those muscles.
7.Consider the possibility of breathing issues
Consider if the patient’s having any breathing issues, are they having a sinus issue? Because certainly a sinus issue could create some short-term breathing issues that sometimes can be correlated to more grinding if there’s more trouble breathing at night.
And certainly sinus issues could cause some inflammation and cause some tooth sensitivity on those maxillary molars if the roots of those teeth are close to the sinus.
Another thing is sleep apnea patients.
There may be a correlation between patients who have sleep disordered breathing, obstructive sleep apnea, and they may be correlated to sleep bruxism.
Sometimes we may want to do a stop bang analysis or screen for sleep apnea if there’s other risk factors and we may want use an oral sleep appliance or CPAP in addition to the night guard once we have a medical diagnosis and a sleep study for the sleep apnea
8.Medications that can affect bruxism
Another thing you should be considering is if there may be medications that affect bruxism. Certain medications patients take may contribute to grinding and bruxism can be a trigger for it, and the bruxism could be a side effect of certain medications they may be taking.
So certainly look at the patient’s medications they’re currently taking. And then on the flip side, there may be some medications that we want to prescribe.
Some doctors may prescribe a muscle relaxer like Flexeril. Personally, I don’t like the longterm management of the drugs like that, but that could be an option.
Something maybe a little easier would be a compounding pharmacy that can make a TMD cream that could be applied topically to the area of the joint to make the muscles feel better. This option could help without a lot of systemic side effects and it could really work on the area that has the issue.
Long-term solutions for TMD
Once the acute pain has been resolved and the patient’s more comfortable, we can think about long-term solutions.
As we mentioned, the physical therapy can really be a tool to empower the patient to help give them exercises that hopefully will reduce the instances of flare-ups over time by keeping those muscles healthier with routine exercises.
You may also just want to just put the articulating paper in the mouth and have the patient bite on it, and especially if we see that there’s a tooth that is sore in addition to some joint or muscular pain.
If there’s a tooth that’s particularly sensitive, check the occlusion with the articulating paper because if there’s a lot of parafunction and bruxism and this tooth has taken a lot of extra work, then the toothache may be related to the grinding.
Correcting the patient’s bite
If there’s an incisor that’s in crossbite and it’s becoming mobile due to heavy forces, we don’t want to leave that in crossbite.
If there’s a palatal cusp on an upper molar that’s in heavy occlusion on the non-working side during lateral movement, so if the lower jaw is moving to the right and there’s a palatal cusp on an upper left molar that’s in heavy occlusion and it’s sore, that’s something to look at.
Or if there’s just risk of cracking a first pre-molar, maybe cracking the first pre-molar because of non-working side occlusal issues.
When we look at it, do we see occlusion that generally has the heaviest contacts on the maxillary palatal cusps and the mandibular fossa of the posterior teeth. And that can be load reducing on those teeth. So certainly you can think about looking at the occlusion.
There may be instances that could benefit from minor occlusal equilibration and or possibly orthodontics for major tooth movements.
But the important thing to remember is that there’s lots of reasons for TMD pain and lots of things that trigger bruxism and lots of things that trigger headaches.
And so we don’t want to lead the patient to believe that just correcting a bite that’s off is going to completely resolve the TMD pain.
But certainly this is something that can affect all kinds of patients at some point in their life and giving them tools to help make them feel better and know how to manage the issues is helpful.
Establishing realistic expectations is important. Helping the patient set realistic expectations that there isn’t a cure but rather a way to manage TMD is important. If the patient can do things that may not stop the symptoms 100%, but can make things 70% better, would they want to try it?