Moderate Damage TMD:

1) Restricted opening

2) Deviation to one side

3) Chewing pain-moderate

4) Ear pain w/o infection

5) Atypical Toothache

URGENT: RESTRICTED OPENING; It is urgent to refer OROFACIAL PAIN SPECIALIST in order to recapture of the completely displaced disc. Why Urgency? The displaced disc will loose it proper shape over time and become permanently displaced and limited opening permanently. Best practice for dentist is URGENT referral to achieve ideal healing in TMD.

Deviation opening to one side, can't move 1/2 distance to opposing side

Moderate damage to TMD is managed by Orofacial pain Specialist due complexity joint, complexity of chronic pain, and anxiety connection to pain. Chewing system orthopedic team is necessary to manage moderate damaged TMD. In chronic pain, the patient is most important member team.

Overlapping Pain Conditions:

1. Overlapping pain conditions increase reported pain
2. Muscle joint pains are mutually additive in pain intensity
3. Tension HA & moderate TMD are highly connected
4. Neck pain & TMD are highly connected
5. Traumas: Blows, Falls, & MVA are highly connected TMD
6. IBS, Hypermobility, Chemical sensitivities, Sinus, Allergies, Fibro,

Moderate Damage TMD includes:

1. Joint, muscles, ligaments, disc
2. Moderate to severe pain
3. Torn lateral ligament disc
4. Disc displacement anterior medially
5. Disc recaptures and displaces full length of disc
6. When displacement gets to medial pole, we have loss most of function disc
7. Medial pole displacement and recapture, changes bite w/ every displacement
8. One causes of atypical toothache, random loading posterior teeth
9. Complete disc displaces can become permanent

Progression of disc damage:

1. Muscle over recruited from multiple sources
2. Pull-stretch-tear lateral ligament of disc for many years
3. Partially displaced disc goes complete
4. One TMD more damaged than another
5. Complete displaced disc is revealed in restricted opening

Hints of moderate damage or destructive grinding include:

1. Bite changes
2. Dual bite
3. Atypical Toothache
4. Atypical Earache
5. Temple or Tension Headache
6. Sensitivity, recession, cervical erosion
7. Moderate wear all teeth, severe wear 1st molar

Damage joint-disc-lateral ligament relationship:

1. Mild damage = partially displaced disc
2. Moderate damage = complete displaced disc
3. Severe damage = bone on bone

Muscle damage or inflammation parallels the damage inside joint; so, a rule thumb is moderate level damage joint accompanies moderate (+) damage in muscles.

At initial examination, if moderate level of jaw joint damage, recent flare in jaw pain, or any slight increase symptoms, the following is recommended:

1. Conservative therapies for two weeks
2. Follow up appointment to see if symptoms have decreased, same, increase
3. Symptom review:
   No symptoms: Educate on flare management
   Symptoms persist: Manage with muscle relaxant & anti-inflammatory
   Reduce stress and clenching
4. Recommend two weeks for follow up
5. Follow up appointment to see if symptoms have decreased, same, increase
6. If symptom increase, refer orofacial pain specialist

At recall, review symptoms of moderate damage

1. History restricted opening
2. Can’t open more 1 to 2 fingers
3. Hints: Temple HA-Atypical toothache-Deviation opening
4. Moderate jaw pain
5. Tried conservative therapy
6. Symptoms grinding/clenching
7. High stress or anxiety

Refer orofacial pain specialist for best prognosis for your patient.

Restricted Opening

Restricted Opening is identified by the following descriptions.

1. Sudden stuck-blocked-can’t open-restricted
2. Open wide loud pop-yawn-destructive brux
3. Can’t open more 1 finger opening,
4. Moderate-severe pain
5. Presentation:
   may come & go
   may get stuck & stay stuck.

Restricted opening hints of moderated damage to TMD for dentist, hygienist. If the patient has an Urgent referral, visit an orofacial pain specialist to increase chance of recapture.

Symptoms Restricted Opening

• Moderate jaw pain
• Frequent episodic or constant
• Throbbing, aching background after sharp pain
• Sharp shooting on function
• Restricted opening: History locking or jaw locked
• Aggravators: opening wide, yawning, chewing, jaw locking, stress,
• Alleviators: muscle relaxants, Advil, massage, hot pak, nightguard,
• Conservative therapies not effective
• Ear or temple pain
• Deviation 1 side opening

A general dentist may accept challenge to treat mild cases (muscle pain or partially displaced disc-click), but if the jaw pain moderate damage they refer to orofacial pain specialist.

Reason for referral to orofacial pain:

1. Joint muscle damage is orthopedics
2. Chewing system orthopedics is medical & dental
3. Manage team of medical professionals (PT, Bio, orofacial)
4. Stress-anxiety-depression-PTSD aggravated chronic pain
5. Material, Design, & Accuracy of orthotic
6. Conservative dental therapies no longer effective
7. Management orthopedic medications
8. Dental appliances no longer effective (Biteguard, Nightguard, Anterior Repositioning Splint, Anterior Deprogrammer =NTI)

Requires team health care professionals:

• Chewing system orthopedic team
• Physical therapist
• Biofeedback -Psychologist-Psychiatrist
• Patient-passionate, health priority

Dental appliances are not recommend for moderate damage TMD:

1. Increase pain
2. Change bite
3. Increase clenching
4. Tooth movement
5. Crowd tongue into air pipe

Dentist & hygienist has three choices with restricted opening

1. Clean-fill teeth and hope no increase in pain
2. Clean-fill teeth and set off an increase pain
3. Refer Orofacial pain stabilize jaw joint before the open mouth procedure
4. Increase sedation for added protection, relax muscle, decrease clench

Anesthesilogist suspects moderate damage TMD (restricted opening)

1. Entubate & hope no increase in pain
2. Entubate setting off an increase pain
3. Refer Orofacial pain stabilize jaw joint before surgery
4. Add benefit of anesthesia relax muscles & reduce clenching

Delay in care:

1. Delays needed care
2. Stabilize-healing in chew system
3. Return for needed care

Patient is referred back to dental professional or anesthiologist after healing and stabilization of TMD. Once jaw joint is stable-healed-nonpainful the open mouth procedure can be done w/o risk of pain flare.

Yes, a delay in care is concern, but the loving care that you show your patient to refer moderate damage in TMD to reduce pain & suffering is incredible.

Caution: if you suspect moderate damage in jaw joint, no open mouth procedure should be undertaken until jaw joint stability and healing have been confirmed by orofacial pain specialist.

Dual Bites

Definition:

In English: Jaw joint bite is different than tooth bite.

In Dental: centric relations is different than centric occlusion

Who has dual bite:

• 85 % have no difference
• 10 % have small difference
• 05 % have moderate difference

A few moderate damage jaw joints have small-moderate difference in dual bite.

Bite Changes

Change in bite:

1. Sudden loss disc
2. Bone loss in TMD

Moderate-severe damage in TMD causes bite changes more than bite causes TMD

Completed displaced disc sudden loss causes condyle to elevate in fossa to load the posterior teeth on one side.

Bone loss in condylar head elevates the whole mandible in posterior to load the posterior teeth on one side.

Atypical Toothache

A toothache in healthy tooth:

1. Majority of dental test negative
2. Fillings not close live part tooth
3. Recent filling w/ history of sensitivity
4. Not related to pulp tooth
5. Adjusted occlusion no benefit

Choices with toothache in healthy tooth:

1. Treat with dental care
2. Refer root canal specialist
3. Refer orofacial pain specialist

Inside nerve verses outside nerve:

1. If you think tooth pain is associated with pulp tooth refer endodontist.
2. If you think tooth pain is associated with outside nerve refer orofacial pain specialist.
3. If you are not sure, refer endodontist. If the endodontist is unsure, they will refer orofacial pain specialist

For anyone so brave and ego centric to think this is always clear, you need to go to endodontist or orofacial pain specialist office to shadow to learn the art of diagnosis difficult cases and respecting the level difficulty.

Diagnostic tree for atypical toothache

1. Pulp tooth-deep crack
2. Outside nerve-shallow crack
3. Muscle refer
4. Joint loading
5. Trigeminal Ganglion referred
6. Atypical Odontalgia
7. Miscellanous