Mild Damage TMD includes:

1. Partially displaced disc (dysfunction)
2. Mild discomfort or no pain
3. Mild to Mod muscle discomfort
4. Joint noise mild infrequent
5. Parafunction & Tension muscles are 2 major causes
6. High Anxiety aggravates pain
7. Trauma, Hypermobility, Dual bites, IBS: causing progression

What causes progression of damage TMD ?

1. Recruited muscles from multiple sources
2. Pull-stretch-tear lateral ligament of disc
3. Comorbidities
4. Multiple pains
5. High anxiety, OCD, Emotional Hyjacking
6. Trauma's
7. Poor health habits

If a dentist were to treat early or mild TMD damage, would the disease progress ? Let's research together:

Conservative therapies for any orthopedic structure is rest, decrease activity, decrease movement, hot packs, Advil.

Conservative therapy is instituted by general dentist anytime they first discover acute pain flares of muscle inflammation and mild joint damage.

At initial or recall examination, if mild level jaw discomfort, flare mild pain, increase tooth symptoms, chewing discomfort: Recommended:

1. Level I: Conservative therapies & NSAIDS
2. Level II: 2 week follow up
   a) Muscle relaxant & anti-inflammatory
   b) Reduce stress and clenching c) continue conservative therapies d) suggested appliance (maybe take impressions)
3. Level III: 2 week follow up a) continue conservative therapies-MR-NSAID b) wear nightguard for 2 weeks
4. Level IV: Refer orofacial pain specialist

The proper protocol in TMD management is recommend conservative therapy in mild damage jaw joints as a first level of care. Recommendation patient return 1-2 weeks after conservative therapies (same protocol for root canals or extractions). If the pain dissipates, you have documentation that conservative management of a mild damage joint or muscle based pain in chewing system was adequate. If symptoms persist, you escalate your care. It is easy to lose track of this minor TMD damage episode because of no follow up or recording data about management. A follow up appointment is required to observe compliance, benefit, and provide patient education about joint damage. If the pain or dysfunction persist in TMD, you may escalate your care to use medications or appliance. Again, a follow up visit is required to properly document your management of this minor TMD damage or chewing muscle discomfort. If pain persist, you escalate care to nightguard. If pain persist, you escalate your care to escalate care to a referral to Orofacial Pain Specialist. This also forms a documentation that you have moderate jaw joint damage requiring a chewing system orthopedic team.

Conservative therapy for mild jaw joint damage includes:

1. Avoid chewing gum
2. Hot compress
3. Low chew diet
4. Massage jaw muscle
5. Ibuprofen 3-4 per day
6. Relax-quiet time-prayer
7. Wear biteguard
8. Avoid opening wide
9. Reduce sugar & stimulants
10. Reduce stress & anxiety

Decrease activity in chewing system:

• Decrease chewability
• Decrease toughness food
• Soft diet
• Low chew diet

SENSITIVITY is early hint of destructive grinding. Escalate your care for progressive or sensitivity resistant to treatment from toothpaste, painting, occlusal adjustment, filling cervical erosions, nightguard, to referral to Orofacial Pain Specialist. Since we are in business of saving teeth, you can take pride in your care by discovering destructive grinding before patient looses teeth to this destructive force.

ATYPICAL TOOTHACHE escalates in symtomology from sensitivity, discomfort, moderate pain, even severe pain despite no evidence of caries or gum disease. The typical scenario begins with filling, then root canal, then crown, then extraction, then implant, and pain persist. Variation to continuing pain is after major treatment, then the pain goes away for weeks to months then returns. This is a problem in that you believe they are better and you stop worrying about the pain ghost and no more follow up. Then month or two later, they are back in your chair for another round testing or referring Endo or OS. With everyone confused on nature of pain, would you think that referral to diagnostic clearinghouse would save time, money, and teeth. In my 40 years of experience, treating the symptoms is frustrating; whereas, treating cause is rewarding.

RESTRICTED OPENING: 1) Hints of moderate jaw joint damage. 2) Requiring urgent referral to Orofacial Pain Specialist. 3) Recapture is dependent on speed referral OFPS 4) Recapture: passion & implementation patient 5) Moderate damage TMD requires orthopedic team 6) Orthopedic Team TMD: Physical therapist, Biofeedback, Patient, Orofacial Pain Specialist

Recapture Potential: 1) age 2) health patient 3) patient passion 4) length time displaced 5) use force reopen 6) stretching when displaced 7) hypermobility 8) health habits

Recapture is return opening to normal (3 fingers) from restricted opening (1 finger). General dentist does not have time to escalate level of care from level I to level 4. If restricted opening or moderate level damage is determined, all dental care should be suspended until disc is recaptured and opening returned normal. This is simple logic since you cannot get handpiece in 1 finger opening mouth. Even if restriction comes and goes, the restriction is not predictable to be ok day of your service. Even more important, you do not want your dental service to get blamed for restricted opening.

If jaw joint damage is moderate, destructive grinding suspected, restricted opening present or history of, a referral to orofacial pain specialist is proper care for your patients. The chewing system orthopedics team will be recruited to stop the progression damage and promote healing.

Hygiene: Recall: Look for hints in all 4 structures for grind-clench, not just teeth 1) Tooth: wear, cracks, fractures, broken, margin breakdown, atypical toothaches 2) Gum & bone: cervical erosion, recession, sensitivity, tori, bone buttressing 3) Muscle: enlargement, trigger points, firmness, compressibility, tenderness, referral pain 4) Joint: noises, deviation, difficult opening, asymmetry, sudden bite changes, post tooth pain

Can you have Chewing System Dysfunction w/o pain. Guideline is damage and pain are parallel presentations. Even though that is mostly true, a person with high pain threshold may have no pain.