Should I add TMD care to my DSM practice?

Dr. Jamison Spencer shows how skills learned for TMD care can also be utilized with DSM. Telemedicine will be a helpful tool for consulting with these patients.

by Jamison Spencer, DMD, MS

Now I know that your knee jerk reaction will be “absolutely not!” but perhaps bear with me for a minute. As I write this we’re going through “a little crisis.” Lots of my colleagues are closed down, other than perhaps seeing dental emergencies.

While some initially rationalized, “hey, sleep apnea IS an emergency” the Governor of their state, and their dental association and board, didn’t tend to think so.

But patients with various TMJ disorders ARE people who go to the ER to see why “their ear ache” isn’t getting any better, or how come they can’t open their mouth as wide anymore.

As such, during the crisis, our practices sent out letters to our colleagues to help them recognize two of the main TMJ problems that could result in a patient seeking unnecessary medical care and thus further clogging the strained system.

I’ll share part of that letter here, and maybe you’ll even learn something.

But the point is do you really want to only focus on sleep?

I know it sounded pretty awesome when you were doing general dentistry and physically beat up. And treating sleep apnea IS awesome!

But many of the skills that you’ve developed in order to help those with sleep apnea can be utilized to help people with various TMJ problems… and it’s kind of nice to have more than one “product” sometimes, right?

Here’s the letter we sent out:

To our esteemed colleagues,

At the Center for Sleep Apnea and TMJ we are acutely aware of the broad effects that Covid-19 is having on all of our colleagues and our collective patients, their families and our communities.

Many in our communities are highly concerned due to the uncertainty.

As you are aware, emotional stress has been linked to increased TMJ disorders and craniofacial pain and dysfunction.

The ADA has asked us as dentists to do anything we can to reduce the level of patients who might present to emergency rooms and other medical providers with dental related problems.

In an effort to perhaps provide some level of relief of medical resources, albeit it small in scope, we would like to provide you with simple guidelines for tentative diagnosis of 2 of the most common TMJ disorders that could result in a patient seeking medical/emergency care.

These conditions are retrodiscitis, or an inflammation of the posterior TMJ capsular tissues, and non-reducing disc displacement, also known as a “closed lock.”

Retrodiscitis:

  • Typically there will be a history of recent trauma, however this “trauma” could also be simply from increased clenching/grinding of the teeth.
  • The patient will usually report pain in or over the TMJ, usually unilaterally. This may also present as or be perceived as an ear ache, which leads the patient to believe they have an ear infection.
  • Typically the patient will report or present with an acute malocclusion, a posterior open bite, on the same side that they have the TMJ/ear pain.
  • Usually the patient will report pain upon trying to occlude, although sometimes chewing on the same side as the pain will be LESS painful (due to the food resulting in space between the teeth and now allowing for full seating of the condyle).

Non-Reducing Disc Displacement:

  • The patient will typically report a history of their jaw popping and clicking, sometimes for years.
  • They will typically report occasional “locking episodes” where their jaw gets stuck for a few seconds to a few minutes. Often they will report that they sometimes wake up with their jaw stuck, but are quickly able to get their jaw to open further, typically with a pop or a click.
  • The patient will often “wake up locked,” unable to open more than 2 fingers between their anterior teeth. It is usually at this point that the patient feels that an emergency condition has developed and will seek out care. This is often very frightening to the patient.

In each of these cases, we are able to at least make a tentative diagnosis via a telemedicine/video consult. We have recently put HIPAA compliant telemedicine protocols in place so that we can virtually “see” these patients without them needing to travel to our office unless it is absolutely necessary.

In the case of retrodiscitis it is common for us to be able to treat this condition with very conservative methods which may not even require an office visit. In the case of a non-reducing disc displacement, typically we refer the patient for an MRI to confirm diagnosis. Time is of the essence. The longer they are locked the more likely they will stay locked. The procedure to “unlock” the disc displacement requires an intra-articular injection and immediate fitting of a temporary splint, which obviously would require an office visit.

Again, we hope that this relatively simple accommodation for any patient that you might have who contacts your office with one of these relatively common TMJ disorders might reduce the odds of these patients seeking medical care and placing a greater burden on the already strained system. We also hope that this will help those of you who have patients who must travel a great distance to come to our office as using this telemedicine protocol we will be able to know at a fairly high level which patients actually will need to come in and who may stay home.

This offer to provide telemedicine consults for your patients will continue for as long as needed.

Should you have any questions please feel free to reach out via phone or email.

We hope that you and your family are well, and hope that this crisis will pass as quickly as possible.

Sincerely,

I really, really, really hope that by the time you read this that the Covid-19 crisis has significantly improved and that life has returned to somewhat normal.

Although that “normal” will be a “new normal.”

Tele-health is going to be something that we now embrace. It is going to allow us to see patients easier, faster, more conveniently and at less expense, and to help catch things earlier before they become chronic.

TMD and DSM will both benefit from tele-health. The patients will still ultimately need to physically see us, but we’ll know they are in the right place before they walk in the door.

If you’ve put off TMD for your whole career because you didn’t feel that the ZERO to a few hours of lecture you received in dental school were enough to make you competent (and you were right), now might be the right time to consider acquiring the skills necessary to provide an accurate diagnosis and a conservative and effective treatment plan.

And, as a bonus, the more you understand about TMJ problems the less scared you’ll be of oral appliance therapy side effects and the better you’ll be able to help your sleep apnea patients. It’s a win-win!

With training in TMD care and sleep, Dr. Spencer has more insights to share. Read his interview here: https://dentalsleeppractice.com/clinician-spotlight/dsp-interview-with-dr-jamison-spencer/.

Jamison Spencer, DMD, MS, is the director of Dental Sleep Medicine for the Center for Sleep Apnea and TMJ, in Boise, Idaho and Salt Lake City, Utah. Dr. Spencer is the Past-President of the American Academy of Craniofacial Pain (AACP), a Diplomate of the American Board of Craniofacial Pain, a Diplomate of the American Board of Dental Sleep Medicine, a Diplomate of the American Board of Craniofacial Dental Sleep Medicine and has a Masters in Craniofacial Pain from Tufts University. He taught head and neck anatomy at Boise State University, is adjunct faculty at the University of the Pacific School of Dentistry, and the University of North Carolina at Chapel Hill. Dr. Spencer created Spencer Study Club, an online education, mentoring and implementation program to help dentists and their teams help more of their patients with sleep apnea and TMJ disorders.

Dr. Spencer now lives in Pleasant View, Utah with his wife, Jennifer, and their 3 children of 6 who are still at home. Dr. Spencer can be reached at Jamison@JamisonSpencer.com, 208.861.5687 or www.JamisonSpencer.com.

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