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In our last Newsletter we covered the basics of how to diagnose patients with clinical and subclinical TMJ problems. These patients can cause dentists many clinical issues and frustrations. Please remember to review your Health Histories and pay attention to YES answers for Headaches. The vast majority of Headache patients are in fact TMJ patients who have simply not been diagnosed properly. A headache history is an easy clue towards helping you start the diagnosis process and “identifying” these patients.
Now, let’s cover some basic post-op problems that we all encounter in the clinic on a regular basis. What if you completed a procedure and the patient has returned several times with post-op problems that appear to be out of the ordinary? Their teeth are sensitive, their bite is off, they can’t chew, they have jaw pain and headaches. Nothing is right. You are being blamed for the problem: “Doc, I did not have these problems before you did this work, now I can’t function.” You re-evaluate the patient and find that
1. Bitewings show that the fillings are not close to the pulp
2. Tooth Sleuth shows that the teeth are not fractured
3. Bitewings show that the crowns have good fit
4. PA Xrays show that the root canals have good fills
5. Occlusal paper shows that the occlusion has been properly adjusted (including carefully rechecking the cusps for composite flashes or bonding agent excess!)
…but the patient is having jaw pain and nonspecific tooth pain. What is this undiagnosed tooth pain or unpleasant dental problem?
We see a large number of subclinical TMJ patients who experience tooth aches that are in fact not tooth related, especially post-op. This is called “ghost tooth ache” syndrome. Often, these patients may be told to receive root canals or extractions to help solve their pain. This is in vain because the problem persists or gets worse. The underlying issue may be neurologic and not tooth borne! Proper diagnosis requires skill and experience. TMJ is normally the underlying culprit so a referral at this point is wise. Go back and review the basics:
1. Does the patient grind or clench?
This is one of the most common and widespread problems affecting a large segment of the population. As the teeth wear down from continuous grinding and/or clenching, so do the joints. The teeth lose their ability to support the proper jaw to jaw balance. Gum chewers can also be considered “clenchers” as the excess stress to the teeth can cause muscle and joint problems.
2. Does the patient have an overbite?
This is the most common of all problems. The probability and severity of TMJ, migraines, headaches, jaw pain, and ear pain in patients who have overbites is over 65%! These patients also have the highest number of post-op problems. Most overbite patients have subclinical TMJ and Headache issues as they were born with a problem that progressed slowly since young age.
3. Did the patient have orthodontics with premolar extractions?
Some of these patients could have a distallized craniomandibular position as their maxillas may have been retruded thereby causing the mandible to shift posteriorly and cause TMJ degeneration. Again, these patients normally have subclinical problems that cannot be diagnosed without MRI or CTScan studies.
WHAT STEPS CAN YOU TAKE CLINICALLY TO MAKE THE PATIENT COMFORTABLE AND ADDRESS THEIR PROBLEM?
Although a comprehensive TMJ evaluation and treatment is required for most of these patients, there are a few things that you can do to alleviate their symptoms:
1. Deliver a NTI, which can be up to 50% effective for most facial pain issues. If you have not taken a course on NTI design and fabrication you can review the videos available on www.chairsidesplint.com. Proper fabrication is critical. I see too many NTIs being made with wrong design and they can worsen symptoms. Many times you will provide this at no charge to regain the patient trust. As an alternative have the patient go to drugstore and buy a Doctor’s Mouthguard to wear at night.
2. If they have an existing bite splint, which has posterior tooth contacts, tell the patient not to wear it. We will cover more bite splint design basics in future newsletters but for now just remember that most bite splints (especially uppers) can worsen TMJ issues especially if they have full posterior contacts. NTIs are much better.
3. Advise patient to go on a soft diet. Mashed potatoes, protein shakes, soups, etc. No food that requires chewing with back teeth. You want to keep that patient from biting their back teeth.
4. No gum chewing. Obviously!
5. Prescribe Flexeril 10 mg h.s. (12 tabs) or Valium 5 mg h.s. (20 tabs)
6. Have them use ice bags when in extreme pain
We are here to help you with these patients and make your clinical life easier.
In the next newsletter we will cover additional clinical issues and how you can address them.