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A SIMPLE TREATMENT FOR A COMPLEX CASE

 

Dr Kathy Jones, from Park Parade Dental Practice in North London, describes finding a brilliantly simple solution for a patient suffering from chronic TMD and being yet more inspired after 33 years of general dentistry.

 

Last year, a 36 year old patient presented with a long history of temporomandibular joint problems, affecting bilateral temporomandibular joints, although this was more pronounced on the right than the left.  When she was asked about the onset of the pain, she recalled suffering from a trampoline accident at the age of 10 in which she traumatised 11 and 12, which later required root canal and apicectomies (Figure 1), and she wondered whether her current symptoms did in fact stem from this time. She complained of a constant dull ache, with jaw stiffness in the morning, in addition to an intermittent pain in her right arm, which she had noticed for the past three to four years, and temporal headaches on the right.  Her aggravating factors for the jaw included yawning and extensive mouth opening, cold weather, pressure on biting the teeth together, brushing the teeth, and eating hard or chewy foods.  Prior to attending our surgery, she had been treated with occlusal bite guards, sulpadine and paracetamol but this had not done a great deal to alleviate the pain.  On clinical examination, there was no lymphadenopathy but there was bilateral preauricular tenderness extending to the temporalis and masseter muscles and there appeared to be a tendency to posture the mandible to the right when grinding at night (Figure 2), evident on the soft occlusal bite guards.

 

Initially, I did not feel confident to treat this patient and, thinking it to be a complex case, had referred her to Eastmans Dental Hospital for a second opinion. Occlusion had always confused me but with an increasing number of patients presenting with TMD, I decided it was time to learn more. I’ve always found taking my nurse of 20 years, Dawn, on courses gives me double the value as we both get so inspired and bounce ideas off one another the moment we get back to work.  Last year, we both attended S4S’ “Occlusal Splints: Predictable Magic for Your Patients” presented by Dr Helen Harrison and followed this up with the “Hands On Splint Therapy” course. Of all the courses I attended last year, this one inspired me the most; it was like pieces of a jigsaw coming together.  After the course, Dawn and I suddenly realised there were a lot of patients we could help in a much more effective way. The “Hands On” course gave me the confidence to attempt to treat some of these TMD cases and we had a great run of success with patients.  After such excellent results, I realised that it might work well with this particular patient.

 

In the first instance, we constructed an SCI1 for the maxillary arch to see if this would alleviate her current nocturnal habit. After so much success using this technique with other patients, I was disappointed when the patient reported that she found it uncomfortable because it made contact with her traumatised 11 and 12.  At this stage, I called S4S and they were most helpful and between us we came up with Plan B – the SCI1 could also be constructed over the lower incisors (Figure 3). The SCI1 constructed in this way was not only comfortable but it also prevented her from carrying out her nocturnal bruxing so the muscles could relax.  Result!

 

At the next review appointment, the patient turned up carrying six bottles of wine for my nurse and me, with a huge smile on her face, her facial muscles looking more relaxed than I had ever seen them and she reported that she had had a 95% improvement in her symptoms including the pain in her arm, which was such a great result after 26 years of suffering. I saw her for another review this week and she is still virtually symptom free and a very happy patient, who now looks completely relaxed. Obviously this case will need monitoring and this may not be the definitive treatment but, in the meantime, it has spurred me on to attend the next S4S course, “Applied Occlusion & Progressive Splint Therapy for Predictable Dentistry”.

 

There is nothing more satisfying than constructing a small, simple appliance that is reasonably priced for the patient and having them return in 90% of cases with their symptoms dramatically reduced.  Even in the short time since we have been providing this treatment, the word of mouth has been so good that new patients have been turning up saying “I’ve heard you’re the lady who can sort out my headaches”.  I liaise very closely with S4S on some of these cases so we can nut out different ways of treating people.  Some patients are clenching while driving or working at a computer so in those cases we have constructed a soft decompression splint for daytime wear combined with the SCI1 for night time.

 

With the confidence I gained from the courses, when faced with an acute case, I can construct an NTI in the surgery in about half an hour to give the patient some immediate relief but I prefer to eventually get the SCI1 made in the laboratory because they are so comfortable with the soft lining and always such a tremendous fit.

 

At last I have found something that really does significantly reduce neck ache, headaches, clenching and premature dentition wear. As it just fits over the anterior teeth, it is unobtrusive and, because it is small and comfortable, patients have no objection to wearing the SCI1.  It is not a total cure for TMD but it is definitely one step better than a normal soft bite guard, as it reduces teeth grinding.  If we can improve patients’ lifestyles by eliminating some of their chronic pain, we have satisfied patients and isn’t that what it’s all about?