Basics of TMD Management – PS016

Teaser:
Taking these broader categories, like how do these typically present in practice to during an exam, or does it chop and change for every patient?

I tell ’em, I’m not a guru. I don’t know what’s gonna work. But can we at least try things that are conservative and then we can always escalate to more aggressive things? 

Jaz’s Introduction:
Welcome back to another Protrusive Student episode. Emma is back after finishing her finals exam. So, in Glasgow where she studies you do the finals exams in your fourth year. And so she’ll be soon heading into her final year, which is fifth year.

So it’s strange that they do their final like academic exams in their penultimate year, but I guess that’s how it works there. And I’m pleased to say she passed. She passed, and she’s back again for this series called Protrusive Students. Now it’s not just for students, it can be provision for someone returning back into dentistry or validation for many clinicians.

Or maybe you are feeling that TMD is not your hot point, and so this is a great basics episode to lift up your foundational understanding. Now, it’s very tough to cover TMD in this short episode, but the main takeaway I can tell you now is the hierarchy of treatment or management is probably a better word than treatment.

We do talk about a few clinical gems and a few pertinent points in someone’s history. Or the common mistakes we make when we’re palpating the joints and the muscles. But if there’s one thing that you’re to take away from this foundational episode on TMD management is the hierarchy of treatment and why it exists.

What are the modalities included in conservative care and what are the modalities that are deemed more aggressive? And why we should have a bit more logic and sequence to how we treat our patient. You’d be able to download my hierarchy underneath the link if you’re on the app. And of course, for the students out there who have exams coming up or want some really good revision notes, Emma regularly updates the Crush Your Exam section.

So in this section on the Protrusive Guidance app, you can access it on your phone or on your browser, anywhere you like, and you can download revision notes. For example, PS006 was indirect restorations, a really good overview for young practitioners and students. And for this episode, you can get everything about TMJ anatomy, which is so important.

How can you understand what pathology is if you don’t understand what normal anatomy is? So to access that, just head over to protrusive app. Make your free account and join the ‘Are you a student?’ section. If you can verify you’re a student, you just need to DM Mari on the app. Her name is Mari Benitez. She’s like our CPD Queen, also student lead.

She’ll just need some proof that you’re a student and she’ll let you access the Protrusive vault, which has got like all our infographics and papers. It’s our way of like supporting and nurturing you students. But like I said, this episode’s also useful for those who have a bit more experience, who are qualified, and you can even get CPD or CE credits for this episode.

We are a PACE approved education provider. For that, you need one of our paid plans, and you scroll down, you answer the quiz. And Mari, our CPD Queen will arrange your certificate. Let’s now join Emma the Protrusive Student and welcome her back for this episode.

Main Episode:
Emma, welcome back, the Protrusive Student. Congratulations for passing your finals like in Glasgow. You do it in the fourth year. Tell us how was it? 

[Emma]
It was intense, but I made it through. I think anyone that’s done final exams before. You’ve just gotta keep your head down for a bit and get through it, really. But I survived. So here I am. 

[Jaz]
Never in doubt, Emma. Never in doubt. I remember we were chatting before you getting results and it’s sometimes difficult to gauge how you’ve done, like I was convinced, I failed. Like it was that one of the OSCEs went that bad. But actually I did end up doing very well and so it was a bit of a family joke now about how I catastrophize.

That kinda stuff. But yeah, it was all good. And now that you’ve been through it, what’s the number one advice you can pass on someone who’s gonna be maybe doing finals next year, for example, or coming up imminently? 

[Emma]
I would say don’t underestimate anything ’cause they will just ask you anything question by- 

[Jaz]
You’re supposed to make it, like you’re supposed to make them calm and reassured that, that’s gonna overwhelm them like to the nth degree. But it is what it’s. 

[Emma]
I think you can either be one of two people. You’re either gonna be someone that knows a little bit about everything or a lot about certain subjects. So for me, I’m one of those people. I like to know a little bit about everything. There’s not one specific topic that is my absolute ride or die or something that I’m bagging on on coming up in the exam. I’m one of those people that like to try and cover everything- 

[Jaz]
And that’s strategy, right? 

[Emma]
I would say for me, definitely. Yeah. But I know some of my friends, they pick the topics that are quite common year after year, and they will know them inside and out, and they’ll compromise on the other topics that they just don’t have time for. Because you’re never going to know absolutely everything unless you’re you and you get a hundred percent in your finals. 

[Jaz]
That was one exam. But with you, what’s the pass percentage? 

[Emma]
I think like in Glasgow, I think it’s around about 60%. 

[Jaz]
In Sheffield, it was 50%. If you get 50%, you can be a dentist. Which coming into it like from a level, right? And like as a 19-year-old and going to dental school and then you get told that, hey, you just need 50% to become a dentist. And I was like, wow. Okay. But it’s tough, right? Yeah. That’s why honors is 65% and then you get your 50%, you’re like, whew, phew.

That was hard kind of thing. Right? And it really puts you in your place. But I think the most important thing is they wanna see that you’re a safe beginner and that you are gonna go out ’cause epitomizes the fact that dentistry is something that you really learn once you qualify rather than in dental school.

And so good. I’m glad you got through that. Today’s episode, we’re talking about something that I like to talk about. We’ve done episodes for dentists in the past, but today we’re gonna make it very student specific for you. TMD, TMJ. How much of the previous episodes on TMD have you listened to?

How much, how much information about TMD have you consumed? I know you’ve got a really good tutor in Glasgow, Dr Ziad Al-Ani, who does wonderful work with occlusion, TMD. So I imagine you, your knowledge is better than the average student, I imagine. 

[Emma]
I think Dr.  Al-Ani is absolutely amazing. We have him a lot in first and second year, and then when we come back to do a lot of TMD and oral medicine and fourth year we go to Dr. Rob Riley. He’s an oral medicine specialists, so I think they teach us a lot. How much is examinable and relevant for new graduates? Unsure, but it’s all things that you need to be aware of. We go pretty in depth for TMJ, TMJD, big topic in Glasgow for exams and things. 

[Jaz]
I’m thinking that you probably know more than the average student about TMD. So like how much background knowledge, is there something that you are lacking confidence on or you are feeling confident on? Like where’s your head space around TMD? 

[Emma]
I would say for TMD, it’s one of those ones I quite enjoy, especially working for Protrusive. Like it’s something that you like to talk about, you talk about quite a lot. So working with you for the last few years and editing those episodes and doing all the notes in them, it is something that I think I have a bit of more of a background on, but it is a big topic, big, big topic. 

[Jaz]
But like it’s one of those things, right, where, yes, you learn about it and then you read them articles about it. You go to the books. But then when you have that patient and they give you this history, and then you are like, whoa, what’s the diagnosis? And then, you think, okay, how do I manage this? It’s actually, it’s one of those things that I think is one of the most difficult things to apply. And Jeff Okeson.

The Jeff Okeson. I’m literally staring at his textbook in front of me. He says that TMD is a thinkers game. Right, very much is a, it’s a bit like ortho, right? Like it’s all the planning, the bracket’s fine, they go where they go. But it’s all about the planning and the sequencing and the diagnosis and that kind of stuff.

So really, I want you to ask away any questions that you think will genuinely help you and students everywhere and we can, yeah, I think it’s nice to go back to basics, but here’s an interesting, I’ll just set the scene a little bit, right? TMD is one of those things, which is like, so debated. So hotly contested, so controversial, right?

And I say this to my patients when they come to me and they expect me to be this like, or, you know, this guru that’s gonna cure them. I’m very quick to educate them that, hey, if you go to seven different practitioners, they’ll give you radically different. So it’s not even like slightly different. Like if you have a broken tooth, it’s either gonna be a crown or a filling.

Very rarely. Or someone might say it’s restorable, not restorable, right? But like it’s gonna be a crown or filling. For TMD though, you have jaw pain. You can go to someone, they will say, you need ortho. You can go to someone and say, you need botox. You can go to someone and say, do you know what?

Just go physio only. You’ll be fine. And so it’s a really tough space to be a patient in general anyway, it’s a very debilitating disease. It’s very, very debilitating. Has a huge impact on the quality of life on our patients, but it’s also more troublesome because as a patient that you are trying to read up on it and you are like, whoa, like I’m so confused.

There’s so much out there, and then also gets carried through as a clinician. Because we then, there’s not just two polarizing camps. It’s about five different polarizing camps. If you listen to Daniele Manfredini, one of my friends, Morten, he went to his like a live thing in Italy, and he will get rid Italian hand gestures and he will bang the table and he says, occlusion has nothing to do with TMD.

Right? And then he will put the splint in and just send the patient away saying, because why? Because occlusion doesn’t matter. Right. Whereas I’m training with Dr. Rob Kerstein, who’s coming to the UK in September. Hopefully we’re organizing that and he’s gonna give me hopefully, what we call DTR certification, which is basically Disclusion Time Reduction therapy, which is basically adjustments of teeth, of their own teeth to get them onto canine guidance as soon as possible.

And you monitor it using these EMG things. And so what he’s saying is occlusion is everything to do with TMD and so I’m looking at these two camps and I’m like, whoa. And then the other three camps are lurking in between. And then there’s a bazillion, gazillion different types splints. So no wonder, Emma, it’s confusing. How can I help? Where do you wanna start? 

[Emma]
So, as students, as we get so much thrown at us, just information to remember and to recite and exams. But in dental practice, and I understand you probably see a lot more TMD patients than the average big time, but what are the most common temporomandibular joint disorders seen in dental practice?

[Jaz]
Okay, so if you can just categorize them broadly into three main categories, there are lots of subcategories. So TMD is an umbrella term, right? It’s a bit like I give the analogy of like, for example, if I say someone has perio disease, we automatically think of like pocketing and chronic perio disease, but actually, perio disease encompasses like a traumatic occlusion causing mobility. That’s the type of perio disease. It could be periodontal disease around an implant like perio-implantitis. It could be perio disease in the form of recession. They just have, they don’t have any like mobility. They don’t have any pockets, but they’ve got loads of recession.

That’s the type of periodontal disease. Periodontal disease has lots of sub classifications and diagnoses. And so TMD has lots of sub diagnoses. So if you look at the actual, official, research diagnostic criteria of TMD, there’s like 13 or 15 different sub classifications. But broadly speaking, it’s muscular.

Okay, so it’s extracapsular. So basically the capsule is that piece of anatomy that sort of encompasses the ball and the socket, i.e., the condyle and the fossa, so everything that happens in that space to do with the disc, and that’s intracapsular. Extracapsular, everything outside of that. So we’re thinking muscles, right?

Yeah. And then there’s osteoarthritis. So this is like classically bone on bone. It’s like a wear and tear disease. So if you look at those three, then the most common is muscular, right? 70%. And then, it’s like a 25% intracapsular. So this is like clicking, locking, clunking popping, that kind of stuff.

Very similar terms used on purpose. And then there’s osteoarthritis. There’s like degenerative, right? So there, over the years there’s been wear and tear. And classically you get crap as they open and close their mouth and you feel this like crunching and their jaw joint. But classically, they don’t have any pain. And so yes, there’s crossover, right? You have all three at once or you have muscular with intracapsular. But those are the broad ones, and muscular is the most common. 

[Emma]
The most common, yeah. So I suppose this is also a very broad question, but taking these broader categories, like how do these typically present in practice to you during an exam? Or does it chop and change for every patient? 

[Jaz]
Yeah, it can be. So TMJ right? It’s called the Miracle Joint, which is Dania Tamimi came on the podcast and said it so elegantly, but it’s also TMD is called The Great Imposter. Did you know that? So you can have like- 

[Emma]
I’m sure I’ve heard you say that before.

[Jaz]
Yeah. Yeah. So you can have like many other issues like tinnitus and headaches and vertigo and all that kind of stuff. But actually it’s a TM joint is a main culprit. So, it’s a great imposter for that reason. So how does it present? We’ll put it this way, because I get referrals for TMD and patients seek me out for TMD and actually as a clinician, I’m happy to say this, I know patients watch my podcast, which I wish they didn’t, but they do, and I’m happy to say that I’m happy to help.

I’m empathetic. I’m a sympathetic, but I’m no guru. Right? I try and follow the best evidence available, which isn’t that great anyway. So I try and do things in a way whereby, okay, let’s do the most reversible and basic things. Safest things first, and escalate from there. And the peak of that would be surgery.

So very few people need to escalate to that. Lower down is botox. Anything that’s irreversible, like orthodontics. We say that until we’ve exhausted, like, education, physiotherapy and appliance, that kind of stuff. Now, going back to your question, how do people present?

And the reason I mentioned why I just mentioned now is when I used to be a purely a general dentist and I would just do a TMJ examination and I would diagnose, did you know you have a click? Or, oh, your muscles are quite sore, aren’t they? And so, that was not a symptom. It was a sign. A sign is something that the we find. But the patient hasn’t quite yet.

It’s like subclinical and so success rate was through the roof because actually it’s not become a big problem yet for them. But now when patients seek you out for this care, then quite often they’ve had it for a long time. It’s very debilitating. It’s like trying to help someone when they’ve got small caries lesion and that it’s completely asymptomatic.

Asymptomatic, so you know that the risk of root canal is so low. Versus they come in and they’re already in pain. And so, you know, pulpitis has started, there’s a higher risk of root canal treatment ensuing. And so it’s more difficult to treat, it’s more difficult to preserve pulp vitality. So I’m making that comparison because when I now see my patients, they have very clear like headaches, jaw clicking, jaw locking.

Whereas when you have general patients, they often have have zero issues. A really good study to look up, Emma, for all our colleagues listening. So it was the opera study, I think it followed like 3000 or 4,000 healthy people who did not have TMD. Right? It followed them up then they saw who got TMD and who didn’t.

Really fascinating, right? Prospective study. And then they kind of looked at these, they studied the people who did get TMD and they found like commonalities. Now they didn’t really go into the occlusion kind of things, but it was like genetic testing. They were often quite in a high state of stress.

They had a few other things. Like they had like tummy issues like IBS, their gentle symptoms. They had other, like back pain, muscular aches around the body. So there was a common trends in these patients. So what that can teach us that it can affects a very specific kind of person.

And in my practice, and also according to literature, it’s like eight to one females to males, eight to one. So we know it must have a genetic or hormonal component if that’s the case. So it’s that kind of a patient that can come to you. And I think one thing, one tip I can add is that if that patient comes to you and they’re complaining of a jaw issue, then Schiffman found a really cool way to figure out, okay, is this patient’s concern more muscular or more joint?

So is it intracapsular or extracapsular? Is that you get the patient to say, can you point with one finger where the source of pain is, and if they point right by their ear, then it more than likely probably is intracapsular something to do with the capsule, the disc, the clicking clunking, that kind of stuff. Or if they’re pointing all over their face or lower down, then it’s probably muscular and that can help you to kind of figure out where to delve deeper into in their history. 

[Emma]
Okay. Yeah, that’s some good, like the clinical tips because just when you’re starting out as a student, you’re just feeling and you’re kind of blind at that point. You don’t really know what you’re looking for. So that’s some good- 

[Jaz]
What you mentioned there, what you’re looking for that, I mean, the top tick in this basic episode is classically when me and Krina are the physiotherapist I worked with and taught with in the past is when we’re calibrating dentists on palpating muscles and palpating the joints classically for the TMJs, we are too far anterior.

We’re like feeling the zygomatic. We’re you’re kind of feeling your cheekbone, right? You go a little bit closer to the ear, right? And then when you get the patient to open a bit and wiggle side side, you should feel the balls of your condyles. Can you try that for me, Emma, right? Can you put your fingers, put your middle fingers that say just in front of your ear, and then open a bit and wiggle your jaw side to side.

Did you feel the balls of your condyles, like against your fingertips, you’re in the right place now. Right? Okay. Whereas classically, if I don’t do that, wiggle bit classically, dentists are too far forward. The other thing I found is that when dentists are palpating the muscles, and we’ll talk about that if it leads that way, we’re being too gentle.

We need to really be a bit more thorough when it comes to muscle palpation. And so it’s very difficult to talk about something that I wanna talk about so much about, but I’m also mindful about keeping this in tune with relevant for early career. People or students, or actually, this could be a good revisiting for someone getting back into practice or someone who actually feels though, you know what?

They ought to just get the foundations of TMD. And so far what we’ve said is it’s an umbrella term. It can present in loads of different ways, but classically, muscular is the most common. But obviously there can be like clicking popping. We can talk about the mechanism of that as well. And just to like calibrate, like make sure you are palpating the right place and you’re able to at least locate the condyle and check the mouth opening. And I guess we can talk about the key things to record, but I want you to lead the show, Emma. 

[Emma]
Yeah, I mean the next question I was going to ask you was, we start basic patient education and you can go all the way up to surgery for treatment options and it obviously depends on the diagnosis. Should we dive into that sort of treatment options? 

[Jaz]
That sounds great. Let me share my screen. So if those of you are listening on Spotify, don’t worry, we’re gonna describe it. But there’s a really cool thing that I want to show, which is like a really nice pyramid, that we’ve been working with, which I also share my patients that I show them, okay, this is where we’re at and this is where we’re heading, and this is how we manage temporomandibular disorders. We don’t treat TMDs. We help to manage TMDs. And they kind of get it and they understand why. A really good thing that Jeff Okeson teaches is that, okay, there’s things that we know are like evidence-based, even though the evidence-based quality can be poor.

And one of the reasons it can be poor is because there’s so much variability, Emma. Like your joint anatomy will be different to mine, just ethnically, genetically, you are a woman. I’m a man. Your tooth contact time, how many minutes a day your teeth come together is different to mine. Your incisive classification is probably different to mine.

And so one of the reasons why the research is so different is ’cause it is difficult to compare. And get good research quality basically in that regard. But it is nice to be able to educate in terms of, okay, why we follow a certain hierarchy. Because as Jeff Okeson says, okay, let’s try and focus on the things that are reversible.

But then, if you are treating someone and you’re doing what we call fringe treatments, treatments, which are, are not really evidence-based, they may be perceived that maybe be a little bit naughty, bit irreversible like orthodontics, but at least you’ve tried all the basic things first ’cause that could have helped.

But then also at least, you know, okay, what I’m doing is on the fringe and to know you’re doing it. The worst thing you could do is do hocus pocus dentistry that isn’t evidence-based. But you’re not, you don’t really know that you’re on the fringe. You know, that’s the one of the worst places to be is what Jeff Okeson teaches, and I really respect that.

Okay, so where we start is patient education, right? One of my mentors, Jamison Spencer, he taught me that TMD patients are nuts. Okay? They’re NUTS, okay? What I mean by that is, is not what you think. It’s NUTS means Not Understanding Their Symptoms. That’s what NUTS means. So we owe it to our patients to educate them, okay?

About their anatomy, about what’s going on ’cause believe it or not, there’s a handful of patients every year. I see that just by education, I don’t like to use the word Cure, but I Manage them. They literally are really help. And even like sometimes telling the patient that our teeth shouldn’t be touching together during the day, and they’re like gobsmacked.

They’re like, what? I thought our teeth should be touching together the whole time. And once you tell ’em that, and then they’re there in the chair, they’re clenching away. And when you tell them that, hey, this is pathological, this is not good. And then finally, after so many years of their life, they’re able to give their muscles rest.

That’s it. They’re essentially managed, right? So we owe it to our patients to give them an explanation. Sometimes the patients are just, they’re not really, are not in pain. They’re just scared. Like, wait, what is this clicking? What’s happening? Am I gonna need surgery in the future? If you just explain to ’em what a click is and we can talk about that, then this is why this education is the foundation. Okay. So, any questions on that before we move to the next bit? 

[Emma]
Well, in terms of education, sorry. Not in particular, no. 

[Jaz]
Okay, so the next thing is, soft foods because we have to remember that the temporomandibular joint is indeed a joint, right? So if you have it as something dodgy, a dodgy knee, well you’re gonna go crutches or put less load on it, or not do strenuous activity.

So when people are having a flare up of their TMJ, so for example, their joints themselves or the muscles, it just makes sense to eat as we had recently on an episode as well. Dr. Suzy Bergman said eat smaller, eat softer. Eat slower, right? Smaller, softer, slower, the three S’s. So it makes sense ’cause it gives the joint rest.

So we educate our patients to do that. As part of education we also say, our teeth shouldn’t be touching together. And like I said, that can be very curative for a lot of patients. We tell them what a click is. So a click, Emma, do you know what a click is? Like what is that click sound? What does that mean? What’s happening to your disc? 

[Emma]
Is that in the disc displacing? 

[Jaz]
So when I open- 

[Emma]
Or reducing it? 

[Jaz]
Let’s, okay, so what does reducing mean? 

[Emma]
So reducing means it’s going back into its original position. 

[Jaz]
Lovely. And so, what Dania Tamimi came on the podcast maybe a few episodes ago, and she had this wonderful way of explaining it, is think not of disc displacement with reduction ’cause reduction is confusing term. Think of it as disc displacement with recapture. By using the word recapture, it really is like a light bulb moment, don’t you think? 

[Emma]
Mm-hmm. Yeah. Yeah. 

[Jaz]
So when you open and that click comes, that’s not what a lot of people think. Even Prosthodontists, I know of the thought this is, that they think that click is bad and that, oh, your disc is dislocating out of position.

‘Cause that click sound means it’s dislocating. No, that click means that the disc is already out of position and that click is the disc returning back onto the condyle is the sound energy of that motion. And so actually it’s a disc displacement with recapture. And so just going back on the education bit there, the next bit in the hierarchy is so TMD education, soft foods, and then ice and or heat.

So, heat is really good for muscle, but sometimes they need to experiment and they do like hot and cold or just cold. Whatever makes ’em feel good is a simple, cheap, minimally invasive evidence-based way to help sore muscles and reduce inflammation. The next one is gentle stretching, because a lot of times your muscles can be in spasm and when muscles are in spasm to allow them to have stretching is really good.

And to actually go forward towards jaw exercises like very specific exercises. Then in tandem with physiotherapy. Physiotherapy has got some decent evidence base when it comes to TMD. Chiropractors on the other hand, don’t have it. So like a patient the other day asked me, should you know I’ve found a good chiropractor?

Should I go for them? I’m like, yeah, you can, because if it’s gonna help my patients and if my patient thinks it’s gonna help ’em, then that’s great. I’m happy for it. But if you have to spend good money, then why not do the more evidence-based thing first? Try the physio first. Knowing that the chiro is probably a little bit more in the fringe.

And so it makes sense. And so physios can be incredibly helpful. Like my physio, I use Krina in central London. She does dry needling, she does red light therapy. She does very carefully targeted exercises. And that can actually improve their range of motion. So initially they might be opening 32, 35 millimeters without pain.

And then after her physio, they’re able to get a 20% improvement in their range of motion. So, that’s there. Anything there before I escalate to the next two, which are more conservative? 

[Emma]
I was going to ask about like, all these stages and about soft diet. So are these things that you would do, the first two in tandem and then you would review after a certain period of time? Or would you just take it step by step by step? 

[Jaz]
Yeah, really good question. I think it depends on who’s in front of you. But most patients. Most patients, right? Because these are all basic things. Like you can do TMD education on everyone. If they’re actively in pain and the one that complaints is that it hurts to chew hard foods, then soft foods, it will be a mainstay ice and heat for those in pain.

But sometimes the patient’s not in pain. They’re just like, they’re getting lock without any pain at all. There’s no pain. They’re just locking down. And again, so for that patient, you may not be necessarily saying, okay, put ice and heat ’cause they don’t have any pain. But it’s more about them giving them specific exercises to strengthen certain muscles to help their coordination, to help them unlock themselves at will.

So, like you can’t go wrong by knowing these. But you might that pick and choose a few of these and emphasize more on certain facets of this, on certain patients than others. And that kind of depends on the micro diagnosis or the problems that your patient presents with.

[Emma]
Okay. That makes sense. Yeah. And about the physiotherapy as well. How, like just out of curiosity, how often are you sending patients to physio? 

[Jaz]
I would say 80% of my patients would benefit from physio. 

[Emma]
Okay. 

[Jaz]
Because it’s like a lot of times if I send a physio, then we may not even need to do an appliance. It just makes sense. And finding a good physio is really tough because there are physios who dabble in TMD and so they’re taking knowledge from other joints and applying it to physio, to the TMJ, which can help. But I encourage patients to try and seek out specifically TMJ specialist physiotherapists and ’cause in physio school, you don’t learn above the neck actually.

So, you need to seek out physios who are specialized in TMJ. So it’s actually not just like seeing a physio, but specifically a specialist, really helps that.

[Emma]
Okay, that makes sense. Yeah. 

[Jaz]
Next one is medications. So, NSAIDs, ibuprofen, for example, if the patient could tolerate it, maxillofacial surgeons may recommend baclofen, which is like a muscle relaxant, something I don’t re-prescribe, but it can be used as well.

So medications have their place. And the last part of conservative care is an appliance, in fact, a random, and there’s mixed evidence when it comes to appliance therapy. But the most recent randomized control trial, this was literally published, June, 2025. So this is like two weeks ago. So it’s in CRANIO, which is a highly respected journal, and its effects of occlusal splint therapy in addition to physical therapy on pain patients affected by muscular TMD.

This was a randomized control. So diagnosis was extracapsular muscular TMD and the patients were allocated into the experimental group, which is basically education, physiotherapy, and splint. That’s the educational group, and the control group is education and physiotherapy. So you always have a control and then you have an intervention.

So the intervention, the way we testing here is, does the addition of a splint actually help? And actually, this is not the first time this study has been done. I’ve seen previous studies done like this, and they found the splint made no difference. So again, evidence-based really varies, but this is a really recent one in a highly respected article, so let’s talk about it.

The primary outcome was TMD pain intensity, and all outcomes were assessed at baseline, at the end of physio, and after six months at the end of physio as well. So there were 27 subjects, 7 males and 20 females. So 27 is not a huge amount, but in these randomized controlled trials in TMD, it’s difficult to recruit.

And this is quite often in TMD lecture, you find that the N numbers are quite low. So let’s go to the conclusion. Findings from the present study demonstrated that pain NDI, which is Neck Disability Index and health related, quality of life improved in both groups. So that’s good. So we know that if you just do education physio, you’re gonna improve your muscular patient.

But only in the experimental group, which was the splint group, these outcomes improved significantly further after six months. So like a few months, they’re both working, but at six months then actually there is a lot of merit in having an occlusal appliance. Thus, our results show that adding occlusal splint therapy to the physical therapy may produce higher positive effects in patients affected by myogenous TMD.

So there we are. That’s hot off the press research. Happy that you asked me that because I’m able to talk about this, and hats off to authors. And then I’ll put that paper, link that paper in the show notes. So that’s why I think it has a place because if there’s bruxism happening, if there’s wear facets right, and they’re overloading their joints, then it sometimes makes sense to put something in between their teeth to prevent that load being transferred onto their joints. And they’re kind of like protecting the joints and protecting the muscles. 

[Emma]
For sure. And I know you mentioned there about splints and bite therapy. What do you offer, because I know there’s so many different types of splints and a lot of opinions on different types. So what do you use in practice? 

[Jaz]
I think in the interest of time, I think I’m gonna say if anyone’s really interested in this, it is a rabbit hole to go down, right? The evidence-based will say that there is no one splint that rules them all. I feel as though I’ve refined some protocols and I’ve got enough patient data now of my own that I do think certain splints are better suited to others, but this is not high quality evidence, obviously, but remember that when it comes to N equals one case studies.

In the world of adhesive dentistry, you have all these like benchtop studies, in vitro studies. Something that one of my mentors, Lane Ochi taught me is that even if you just have one case report, N equals one, one case report. Okay? Involving a real patient that’s already better than any in vitro study ever done.

Because that’s involves a real patient, right? So I think there’s a lot to be said about that. But if anyone’s interested, going down this rabbit hole, two resources I can link to this podcast. One is a flow chart I made, which pretty much summarizes my decision making in appliance therapy when it comes to permissive spints.

These are splints that are not guiding the jaw anywhere and the jaw goes wherever it wants to go. Think of soft bite guards, think of Michigan splints, thinks of hard occlusal, flat splints, that kind of stuff. So I’ll link, I make sure, Emma, that we link that flow chart. And also we did, I did a couple of episodes, which is, Which is the Best Splint?

There was actually a whole episode about that. So I think let’s direct our listeners to go down this rabbit hole. I think everyone needs to do their due diligence. But in a nutshell, if it’s a muscular patient, I find something like a B splint quite helpful, which essentially the back teeth are not able to touch.

So if you try it on yourself, Emma, can you clench on your back teeth and put your fingers on your, like forehead region overhead? Just side ahead. Lovely. Bite together on your back teeth. And tell me what you feel on your hands. 

[Emma]
You could feel like your muscles portrayed in there. 

[Jaz]
Did you feel a bulge? Did you feel a bulge on both sides or just one side? 

[Emma]
Both sides. 

[Jaz]
So you have already a, more than likely a healthy masticatory system because a dysfunction patient is basically that bites so off that when they bite together one side bulges and the other one doesn’t. Or it bulges asynchronously. So one side bulges and then, then like a second later, the other one goes.

Okay. So if they bulge at the same time, that’s good. And then feel your masseters. Can you go and feel by like the angle of your jaw a little bit lower down for me? A little bit lower down? Yeah, a little bit. Yeah. And now bite together and feel the bulge there. Do you feel that? 

[Emma]
Mm-hmm. 

[Jaz]
Okay, good. So a certain type of splint that when you are clenching together, you are not able to contract. It’s a bit like if you hold a pencil in between your front teeth and you try checking those muscle contractions again, you’ll feel a small fraction of that power. So I find splints like that are really good for the muscular groups, basically to just to give some sort of value to that. So after you’ve done all that conservative care, conservative non-invasive care, so conservative once again, TMD education, soft foods, ice and heat, gentle stretching, jaw exercises, physiotherapy, medications, and an appliance therapy specifically appliance that does not aim to change the bite.

Then what you do is you evaluate. Okay. And then after the evaluation, and then you see, is the juice worth a squeeze? Are the risks of aggressive treatment worth it? And then the aggressive treatments, which we’re not gonna go to go into in this more basic episode, but is bite adjustment orthodontics, crown and bridge work and surgery.

Okay. And then encompass within that as well is botox and stuff. Right? That’s a little bit more aggressive. It’s like the interface between conservative and aggressive. I would say botox somewhere in the middle which kind of paralyzes the muscles, but that’s kind of the mainstay of how we can, in the absence of high quality data manage TMD. Any questions on that? 

[Emma]
Yeah. So you show this to your patients, don’t you? 

[Jaz]
Yeah. I basically talk ’em through it. I talk ’em through it, because the problem with- I say the problem with TMD patients, I bless them, they’ve often been fobbed around and they are, like I said, they’re NUTS.

They’re not understanding their symptoms and they’ve been down this dreary pathway or researching everything and they are really confused at what’s going on. And so they already have like preconceived ideas and unfortunately there’s so much marketing to these TMD patients and then messages like, Hey, you need ortho.

Hey, you need this approach. Hey, you need a misalign to cure your TMD. And so bless ’em. They’re so confused. And so I say that, look, maybe that is the right way. I don’t know, but this is what I believe in because I tell ’em, I’m not a guru. I don’t know what’s gonna work. Can we at least try things that are conservative and then we can always escalate to more aggressive things.

And that to me goes, that for me is a rational way to explain it. And my patients understand it. I think the way I explain that, they get it. They understand that I’m on their side. I don’t want to go straight to surgery unless it’s genuinely needed. I don’t want to go straight to botox unless we can do patient education and physio first before we escalate. And I think my patients have received that really well. 

[Emma]
And I think we learned similar in Glasgow. You know, start off with the basic things, the obvious things, and work your way up. But, even for me, I’m struggling with, or was more so when I was stressed during exam, struggling with grinding and a sore jaw and things like that.

It’s calmed down a bit now, but even then it was just me as a dental student still just didn’t really know what to do about it. So there’s so, so many opinions in TMJ and TMJD, so it’s a hard one. But yeah, definitely that flow chart as well, that you were talking about, just lays it out nice and simple as well.

[Jaz]
Great. So we’ll make sure we reference all those. And I think one more nugget I can give to make it as valuable for everyone spending time listening to this, but like you mentioned, you are stressed, right? And so stress is something to do with it as well. You are probably clenching your teeth some more.

So muscular overload. And then a really cool clinical tip I can give you is if the patient says their pain is worse in the mornings or the pain is worse in the evenings, that gives you a clue. So if the patient’s waking up in pain, then that could be the overwork, the dental gymnastics happening in the night.

But if this pain, like they feel great in the morning, but by the end of the day their muscles are really burning, then that could be something that’s what we call awake bruxism. And the interesting thing about bruxism is that fascinatingly bruxism is not even linked to TMD. We haven’t even established those links, so let’s not even go down that rabbit hole just yet.

But for some patients it can be a big deal. Because muscles get overloaded. But if someone is even thrusting their jaw forward, like holding their jaw forward without touching their teeth, yeah, that’s still bruxism. That’s still a pathological thing. So what we end up doing, especially as dentists, we’re like in this strange posture.

And I speak to dentists all the time that jaw is in this funny position, and as dentists, we suffer a lot with TMD, muscular TMD ourselves. And so it’s about making sure that you are respecting your jaw posture, you’re keeping everything relaxed. You’re not keeping holding tension in your jaw because that could be a big part of your TMD story because even you transiently, you had TMD. Yeah, muscular TMD by the sounds of it.

[Emma]
Yeah. And it wasn’t until recently that I really noticed it. We were doing intraoral scanning at uni for like at the end of our exams. We go back for a few weeks. Dr. Maddison said to me, he was like, oh, hundred percent you grind your teeth in your sleep. And then, I have a partner now. We’ve only been together like a few months, and he was like, you grind your teeth and your sleep.

I woke up one night and I was like, what the hell is she doing? And I was just like, chomping my teeth away. So that is not actually something that I was ever aware of either. But I notice it now, so I’m trying to stop. 

[Jaz]
Wow. Okay. So interesting. Let’s talk about that. Because when you tell patients, right, it’s like, well, we call it Grind Scene Investigation. Okay. GSI. Okay. Not crime scene, Grind Scene Investigation. Because when I was a newly qualified, I say to a patient, Hey, you grind your teeth, and you know what patients say? Like, no, I would know. I would know if I grind my teeth.

Yeah. I would know. My partner would’ve told me. Kind of thing. But here’s the thing, right? I think it is like kind of like catching a solar eclipse. Seeing your partner grind, right? You have to wake up at that exact moment in time. It’s dark. Okay? You wake up that exact moment in time. You often don’t make any sounds when you’re grinding.

And then how many minutes night are we actually grinding? It’s like 8 to 15 minutes for a severe bruxist. And so to catch that, the few seconds of burst of grinding activity. And that’s why the patient, like when you ask patients. If you grind your teeth self-reported, then the instance is low.

But if you look at the wear sets, the instance is high. So actually go by the grind scene investigation. So you never say to a patient, you grind your teeth? You say this, you say patient, did you know that you had the signs of teeth grinding? So you as a dentist, we take control because either they don’t know that they had the signs of teeth grinding or they do know that they had the signs of teeth grinding.

It’s not like a blame thing. It’s like, hey, you’ve got the signs of teeth grinding. Okay. This is the grinding scene investigation, therefore you have been right. So it may not be active, but I can see evidence of it kind of thing. So maybe we have to, to do an appliance for you, Emma, and we can talk about that.

One thing we’re introducing to Protrusive is Pathways, right? Because I noticed we got so many hours of content on our podcast now, and I feel as though we want to invite everyone. Like if you wanna go down the TMD rabbit hole, we probably have like 12 to 15 hours you can consume just on TMD and have like a mini diploma in that, right?

And be able to help your patients. So what we’re gonna do is, I’ll link below the playlist for all the splint and TMD type bruxism type episodes that you can go down the rabbit hole. But similarly, like everything around bridges, everything around onlays and crowns will have its own pathway. So we’ll release these Pathways.

By the time this is published, this will be out there. And so I would encourage everyone to delve deeper and hopefully this is like a nice little, wet your feet and an introduction to TMD. We could go days and days talking about this, right? But it is one of those things that it’d be a nice to have this conversation, but I think it’d be a disservice if we try and just distill all of it, but now we can lead them to the Pathways which are available for free.

Obviously if you wanna get CPD, then join one of our paid plans, help support Team Protrusive and what our mission, but. Any burning questions, Emma, based on our chat just now? 

[Emma]
None at the moment. I think that was good for me as well to maybe learn a bit more at the end there about my own possible problems with my TMJ and my pain that I’m having at the moment. But no, it was good. Good to be introduction, definitely. 

[Jaz]
Good, good, good. And maybe you can do a part two next year and build on this. What else, do we have any student notes? Like you, obviously you’ve been uploading your student notes in the Crush Your Exam Section of the app.

[Emma]
Yes. So I’ve made some student notes for TMJ, not so much TMJD, but more just about the TMJ cavity movement and- 

[Jaz]
Anatomy. Perfect. I was just gonna say that the top tip I’d give to everyone starting out is learn the anatomy. Like it’s so, so, so, so crucial. The muscle insertions and origins, what the disc looks like, because once you understand the anatomy, you can understand disease.

[Emma]
Yeah, for sure. 

[Jaz]
When mechanical disease is relevant to TMD and sometimes it is. So that’s a really key one. Also, in the future, if you’re doing bigger cases, reorganizing the bite. It’s important to have this knowledge to be able to assess a healthy joint, which will allow you to proceed to give that level of care. 

[Emma]
A hundred percent. Yeah. So a lot of anatomy and then just at the end, there’s a very small, like, basic understanding of TMJ dysfunction. Just a very small bit there. 

[Jaz]
Amazing. So if you guys wanna catch that, check out the Protrusive Guidance app, the website, protrusive.app. It’s free if you message Mari on the app, um, then she’ll be able to get you onto the secret student section, which gives you access to Protrusive Vault as well. But Emma, what have you got planned for the rest of the, I guess the version two, season two of Protrusive Students now that you’re a free woman. 

[Emma]
And so again, yeah, a free woman at the moment. Again, just going through, I actually have a list of potential topics. I know that we just did one on communication and we’ve got a lot of episodes on oral medicine, but maybe just some a student version, oral med, oral surgery, medical history. We’ve not done anything on endodontics yet, but just some basic understanding of those kinds of topics, so- 

[Jaz]
It sounds great. Okay., I’m excited. Let’s do it. So, whatever you decide, I mean, whatever serve the students the best, we will do it. And thanks for the wonderful notes that you make for us. And I’ll see you next time. Thank you so much. 

[Emma]
See you next time. Thank you. 

Jaz’s Outro:
Well, there we have it guys. Thanks so much for listening all the way to the end. Like I said, you can download the PDF of the TMD hierarchy on the Protrusive Guidance app. Just head over to protrusive.app on your browser, and then once you sign up, you can then actually download the Android or iOS app.

But it’s really important to make your account first. For the students, you’ve got your own space, but for everyone, we’re a very inclusive community. As long as you’re a dental professional, we are here to support and grow together. We are the nicest and geekiest community of dentists in the world. That’s like our tagline.

And if you listen all the way to the end, like you have done, and you are a real qualified dentist. I use the word real because recently in the news there was like this check dentist who was like fake and he was like YouTubing procedures, and he got away with it for a few years. That’s absolutely crazy.

But anyway, if you are a real dentist and you wanna get CPD and CE credit, this episode is eligible. You can get over 350 hours of CE on the Protrusive Guidance app from clinical walkthrough videos to our bread and butter episodes. So do check it out and remember to share the love if you find that this podcast is helpful to you, your colleagues, your associate.

Your mother-in-law, if she’s a dentist, might find it helpful as well. So please send it to everyone. And I thank you once again for sticking with us all the way to the end. I’ll catch you same time, same place next week. Bye for now.