'I started Clear Aligners and now my Jaw is hurting!'
This highly inconvenient problem could start after any type of orthodontics, it is not limited to Aligner therapy, of course. It is a query some colleagues have sought advice for and I hope to share some food for thought in this article.
How to PREVENT Mid-treatment TMD
It all starts with the initial consultation. By taking a detailed history that includes asking about:
History of clicking, popping, locking
Jaw mobility issues
A changing bite in the last few years
Headaches
Pre-auricular pain
Awareness of Bruxism (awake or nocturnal)
History of Trauma to head and neck
A positive history should be investigated further and a diagnosis made following a detailed clinical examination including:
- Measuring the range of movement - the 'quick and dirty' way of checking is whether the patient can insert 3 of her fingers in her mouth between the incisors. A mouth opening of less than 40mm should not be ignored. On the flip side, an opening more than 55mm may indicate a hypermobile joint which also predisposes itself to TMD
- Palpating the muscles of mastication, with particular emphasis on the insertion and the origin of Masseter and Temporalis. Lateral Pterygoid muscles cannot be palpated but can be tested against function.
- Noting any clicking and the timing of a click - a late click is assumed to be a sign of a less stable disc-condyle relationship
- The path of mouth opening should be straight and smooth - any deviation from this should be noted
- Checking for intra-oral signs of parafunction including attritive wear facets, cheek ridging and tongue scalloping
Any abnormal or positive observations from the history and examination should inform the risk level of the patient. The two most common Temporo-mandibular disorders can be classified as Myofascial (Myalgia) and Intracapsular disorders.
If a positive diagnosis is made, then orthodontic treatment should be delayed until the myalgia (muscle pain, diffuse pain around the face, tension headaches) or intracapsular disorder (locking and popping jaw, limited opening) is investigated and treated. This could be with advice, physiotherapy and/or an occlusal appliance as part of the Conservative management of TMD.
Diagnosing such issues will reduce any TMD surprises in the middle of treatment.
Managing TMD DURING Orthodontic Treatment
Firstly, do not panic! You must reassure your patient and listen to their problems. You need to establish if their concern is myofascial or intracapsular.
Intracapsular signs and symptoms: sharp pain by the ear, locking of the jaw, pain on opening beyond 20mm. Myofascial signs and symptoms: diffuse pain around the face, a tired jaw, headaches, a dull ache from the jaw.
Myofascial disorders usually have a better and more predictable prognosis than intra-capsular problems. Thankfully, myofascial pain is the most common form of TMD.
The orthodontic treatment has likely upset their muscles and/or joints as they likely had a pre-existing history of TMD and a narrow 'adaptive capacity’.
Remember that TMD, like other muskuloskeletal disorders, does not necessarily arise from tissue damage only - there is much more to developing a TMD including the patient's perception of pain and their cognitive state. This is the current and accepted Biopsychosocial model of TMD.
This is why conservative care also includes stress management and mindfulness. Beyond this, the physical impairment can be managed with:
- A temporary splint such as an Aqualizer - this is essentially 2 small water filled sacs that are placed between the molars and help to rest the joints and muscles and decompress the joints. These can be purchased from https://www.sident.co.uk/
- TMJ Physiotherapy - you can find a local physiotherapist who can help with TMD via acptmd.co.uk
- Analgesics such as NSAIDs and paracetamol. Topical NSAIDs gel can also be applied to the joint area with the advantage that it avoids the systemic upset that may be caused by NSAIDs
- Ensuring that the patient is made aware of the deleterious effects of awake bruxism. The mantra should be 'Lips Together, Teeth apart'
- Heat application from a warm flannel over the muscles
- A temporary soft diet
Conservative care can be highly successful for the management of TMDs. A period of monitoring of 2 weeks should be considered before continuing with active treatment. Irreversible procedures such as occlusal adjustments and surgery should be kept as last resort.
If you would like to become more confident in the diagnosis and management of TMD as a GDP, join the next cohort of SplintCourse. Enrolment opens on 8th November 2021. The course is 100% online
Register your interest now at www.splintcourse.com
