Welcome to our first TMJ newsletter. Our goal is to help all of our referring dentists and health care professionals with patient management and common clinical problems. Additionally, patients can review some of this information to help themselves with any clinical difficulties.
In day to day dental practices dentists are faced with many clinical problems during and after completing dental procedures. One of the most frustrating problems for patients and doctors alike is the issue of NOT being able to achieve profound anesthesia. The second most common irritation comes from patients who always seem to have post-op problems (severe sensitivity, trismus (tight muscles that prevent opening the jaw), facial pain, fillings that do not bite correctly, vague tooth aches, headaches, etc.) This and future newsletters will shed some light on how to handle and deal with these common problems, whether you are a doctor or patient. The majority of the patients that exhibit these type of clinical problems can possibly be TMJ patients. Some are easy to diagnose as TMJ patients because they already know about their problem or they have some symptomatology with their joints (pop, click, crepitus, pain upon palpation, limited opening, etc.) Some patients, however, are classified as subclinical TMJ patients and they do NOT know or exhibit any obvious symptoms other than histories of headaches. “Subclinical patients” normally have chronic pain problems and can experience difficulties to dental treatment.
Let’s review some of the more common characteristics and get some down to earth solutions for handling these issues.
1. Does the patient have a hard time getting numb for dental procedures?
More than 3 injections have been given and the patient still feels everything. They are not numb. If anesthesia is NOT achieved after the 3rd injection then the recommendation would be to STOP. Go back and review the Health History to see if the patient has ever been diagnosed with TMJ or if they answered “YES” to any history of Headache problems. If YES, realize that many TMJ patients may be hard to numb for mandibular (lower jaw) procedures. Chances are high that they may have a hard time with normal dental care. The doctor must take the time to re-evaluate and educate the patient about TMJ.
If NO clinical TMJ problems are noted then go back and review the medication regimen and pay careful attention to antidepressant, anxiety, and neurologic meds. Wellbutrin, Elavil, Pamelor, Celexa, Prozac, Imitrex, Neurontin are just some of the more common of the enemies that wreak havoc on nerves and make patient management difficult. These meds can contribute to increased clenching and bruxing, which leads you right back to a TMJ issue! Similarly, illegal substances such as cocaine, meth, LSD, and heroin can cause abnormal nerve function and the patient may may not be able to achieve anesthesia.
Another factor that can contribute to anesthesia tolerance is due to excess coffee consumption. ALL patients should NOT drink coffee at least 12 hrs before their visit!
If there are no obvious clinical signs of TMJ issues and there are no contributing medication problems then the blood pressure should be rechecked. High readings can cause dissolution of the anesthesia and could be an indication of possible high “anxiety.” If the BP is within normal limits then some Marcaine intraligamental injections directly into the PDL of the tooth can help. This may work many times but the anesthesia can wear off quickly so long procedures or quadrant dentistry may be tough to accomplish. Other strategies that can prove successful are Sedation alternatives (NO2) to help calm the nervous system.
If the patient has been diagnosed with TMJ problems (which is normally the most common factor) please realize that TMJ syndrome causes the trigeminal nerve to be tolerant to the effects of the anesthesia so the treatment may be difficult to complete. If there are no obvious clinical signs of TMJ problems (no TMJ pain, no popping and no clicking) and no contributory medication problems, then you can suspect a subclinical TMJ issue. Review the following questions:
– Do you have a history of Headaches or migraines?
– Do you clench or grind your teeth?
– Do you chew gum?
– Do you have ear pain, tinnitus, or sinus problems?
Doctors: If you simply review the Health History you will see that many patients have checked off the Headache question as positive! Some may have forgotten to do so because they don’t think it’s necessary to tell their dentist about Headaches. Ask them again! Any Yes answers to above questions will lead you towards advising the patient to have a more in-depth TMJ analysis.
Subclinical TMJ patients usually present with the highest number of clinical issues. These patients normally have a history of headaches or migraines with no obvious TMJ symptomatology. Subclinical patients can only be diagnosed with proper XRays and MRI studies. Panorex XRs cannot be used. Most of these patients have plasticized TMJoints which have undergone slow degeneration. With these patients, a proper TMJ evaluation is needed!