Protocols for TMD and Bruxism Risk Management
By Dr. Bradley Eli, DMD, MS
Developed by Orofacial Pain Specialists for use in dental and medical practices.
How to address an acute TMJ injury?
Until now, there has not been a universal treatment protocol for addressing acute jaw injury with simple and conservative measures targeted at preventing the development of TMJ disorders (TMD). TMDs are a common group of conditions with a collective prevalence that ranges from 20% to 40% in the general population. [1]
Since 2016 our jaw pains specialists have emphasized the importance of early intervention, which we call “speed to treatment” because there is a narrow therapeutic window where conservative therapies have the potential to engage, motivate and promote healing for patients. Early intervention is important to interrupt the progression of acute TMJ pain and/or dysfunction to persistent TMD.
- Protocols for TMD and Bruxism Risk Management
- 30 Diagnostically Different TMJ Disorders
- Compare an Ankle Sprain to Jaw Sprain
- What does H.E.A.L.S. mean for JAMSS Patient Self-care?
- Helping People Proactively Care for JAMSS Symptoms
- Who Developed the JAMSS Protocol?
- What is the Dental S.A.F.E. Protocol?
- What is the Jaw Parafunction Risk Rating Protocol?
- Clinical Protocols Conclusion
Using the term JAMSS, for Jaw Joint and Muscle Sprain/Strain to describe acute injury and/or trauma to the TMJ complex is encouraged by James Fricton DDS, MS, Professor James Elliott, PT, PhD, FAPT, and Dr. Bradly Eli. Normal expected recovery for JAMSS is two to four weeks. Healthcare providers generally share a common understanding of the M.E.A.T and R.I.C.E protocols for addressing an ankle sprain, knee injury and treatment for other joints. Healthcare providers agree that following these care models as soon as possible is important to reduce pain and inflammation, preserve range of motion, and prevent further complications.
The same should be said for JAMSS injuries, and yet, until recently there has not been a simple application of the RICE and MEAT Protocols that could be implemented by dental and medical professionals.
In 2020, the National Commission on Recognition of Dental Specialties and Certifying Boards recognized orofacial pain (OFP) as the 12th specialty in dentistry. Recognition of this specialty solidifies another link between dentistry and medicine, acknowledging that the orofacial region, oral cavity, and masticatory system are an integral part of total patient care. [2]
30 Diagnostically Different TMJ Disorders
A JAMSS injury is an acute condition with “sudden onset” syptoms. It is included in a heterogeneous group of 30 diagnostically different TMJ disorders. Most of the TMD literature and treatment options to date refers to TMJ pain and dysfunction that has lasted more than six months. There exists specific Medical ICD-10-CM coding (a standardized classification system of diagnosis codes in all healthcare settings) for Jaw Sprain S03.4- (in levels of detail.) [3]
The emphasis of these suggested protocols herein is simple diagnostic tools and treatment aids to identify and prevent JAMSS. Join us in your healthcare community in raising awareness of the availability of simple steps to intervene with treatment to promote timely recovery, and promptly identify patients requiring additional care.
We have developed a common protocol for medical and dental providers, called the JAMSS Protocol.
Explaining the components M.E.A.T. and R.I.C.E. for Jaw Pain
| M | Movement |
|---|---|
| E | Exercise |
| A | Analgesics |
| T | Treatment |
| R | Rest: |
|---|---|
| I | Ice |
| C | Compression |
| E | Exercise |
Compare an Ankle Sprain to Jaw Sprain
Unlike a sprained ankle or knee which can be rested, the temporomandibular joint region and associated muscles, tendons, and ligaments are used for swallowing, chewing, speaking, and smiling, and thus are difficult to immobilize. Another significant challenge in treating JAMSS conditions is the delayed onset of TMJ-related symptoms from common situations like sports injuries, dental procedures, or slip and fall accidents.
The National Academies of Sciences, Engineering, and Medicine (NASEM) report on TMDs talks about the existing gap in agreement among healthcare professionals that specifies a distinction between initial TMD and its chronic stage. The consequence is that the end of acute TMD pain is most often indeterminate” (NASEM, 2020)
This poor understanding of the transition to prolonged TMDs is possibly responsible for the lack of cohesive preventative strategies up until now. The NASEM report points out that the underlying pathophysiology so closely resembles that of other chronic pain disorders such as back and neck pain. Recommendation 5 of the NASEM Committee states:
Diagnostic tools and resources for TMDS should be improved for the initial assessment by primary care clinicians and dentists and for referrals to specialists as needed. These efforts should include the development of decision criteria for risk stratification to aid in identifying patients who are likely to escalate from self-limiting and localized symptoms to a systemic pain condition and then to high impact pain.” – Temporomandibular Disorders: Priorities for Research and Care [4]
The JAMSS Protocol shares the following objectives in common with M.E.A.T. and R.I.C.E.
- To reduce pain
- To minimize disability
- To prevent further injury
- To minimize the chance of chronic pain or dysfunction
- To promote recovery over a two-to-four-week period, and identify patients who are not improving that may need care from a specialist
Finally, for TMJ-related pain, lack of treatment or delayed treatment is the single greatest reason for the development of persistent or prolonged pain. Patients wait, or do not know where to go for evaluation and care.
What does H.E.A.L.S. mean for JAMSS Patient Self-care?
Orofacial Therapeutics advocates for a patient-centered acronym – “H.E.A.L.S.” because patient self-care is so important. Ups and downs in the recovery process are common and because of this, developing a consistent daily self-care routing is important. Pain in the TMJ region is stressful, because of the biologic importance of the masticatory system and facial region. “The disease model for TMDs has changed from a dental-based biomechanical model to a whole-person biopsychosocial model that incorporates mechanism-based evaluation, management and prevention.” [5]
| H for Heat/Cold/Massage | Applications of heat and cold can relax the jaw and neck muscles and reduce inflammation and pain. Heat and massage increase circulation and facilitates mobility. |
|---|---|
| E for Exercises | Gentle exercises circulate synovial fluid, remove metabolic waste and preserve the range of motion. |
| A for Analgesics & QuickSplint | Anti-inflammatory and pain reducing medications reduce joint and muscle pain. QuickSplint is an oral device worn during sleep to decrease jaw muscle tension and guarding through joint unloading. |
| L for Lifestyle | Focus on positive choices to promote healing such as a soft diet, careful chewing on both sides, proper tongue resting position, relaxed breathing and facial muscles, and adequate sleep. |
| S for Stress and Strain Reduction | Reducing muscle-tensing habits and activities that put a strain on the neck and jaw joints and muscles such as: eating or biting hard/chewy foods, chewing gum, opening the mouth for too long or too wide, overuse of the jaw for singing, musical instrument or any other reason. |
Helping People Proactively Care for JAMSS Symptoms
We hope that you will join us in promoting awareness that patients need to be proactive in caring for JAMSS symptoms. Keep in mind these common clinical scenarios that often result in TMD conditions that may have been prevented with early intervention:
1. Direct TMJ trauma, from sports injuries, motor vehicle collisions, physical violence.
2. Whiplash-related injuries from collisions, falls, sports injuries.
3. Hyperextension (intrinsic) injuries from dental procedures, intubation, oral sex.
4. Strain from repetitive or continuous muscle activation, from bruxism, nail biting.
Based on our advanced training in orofacial pain, we promote adoption of the JAMSS Protocol as a common treatment plan for jaw sprain/strain that can be incorporated by any medical, dental, or other frontline healthcare provider.
Who Developed the JAMSS Protocol?
The JAMSS Protocol was developed by Bradley Eli, DMD, MS, and James Fricton, DDS, MS, Diplomates of the American Board of Orofacial Pain, and Lee Ann Brady, DMD, Clinical Education Director at the Pankey Institute.
This protocol is an orthopedic model of care and does not require advanced training in craniofacial conditions, nor does it require the use of specialized dental equipment. The JAMSS Protocol is a multimodal approach to therapy, meaning that it includes short-term use of an oral appliance, cryotherapy, thermotherapy, physical therapy, and behavioral pain management.
We carefully designed QuickSplint® and the Speed2Treat® Home Healing Kit for ease of use across healthcare providers, administered at the time of injury or evaluation. Use of the Speed2Treat Home Healing Kit is not a substitute for appropriate medical evaluation, however in our experience too many patients with a JAMSS injury lack access to any care in a timely manner. We estimate that up to 80% of patients treated with the JAMSS Protocol will return to normal function and the remaining 20% of this patient population will be identified promptly with initial treatment results that aid further differential diagnosis.
You may use other commercially available products (ready-made or custom) in implementing the JAMSS Protocol. Keep in mind, however, that an over-the-counter “boil and bite” appliance is typically made of soft silicone and guards of this type do not keep the posterior (back teeth) out of occlusion. If this design of an oral appliance is used, or if it is soft enough to feel chewy to the user, it can increase jaw muscle activation during use. This often increases pain and muscle guarding.
What is the Dental S.A.F.E. Protocol?
The S.A.F.E. Protocol was developed by Drs. Eli, Fricton, and Brady to help all dentists prevent JAMSS injuries from dental procedures.
Sustained mouth opening frequently occurs during oral surgeries and long dental procedures. This represents a risk for TMD development if not treated promptly. The S.A.F.E. Protocol defines a pre-treatment risk assessment to help identify and manage a high-risk patient and/or higher-risk dental procedure.
The Preventing chronic pain after acute jaw sprain or strain article by James Fricton, DDS, MS; Brad Eli, et. al, states that “92% of these patients with acute jaw pain had improved their pain within 4 weeks with 90% moderate to excellent satisfaction”. Published on August 30, 2016, in The Journal of American Dental Association, it also includes the following table.
Table 3 Results of using the speed-to-treat protocol for jaw sprain or strain at 1 month in a randomly selected group of patients with acute jaw pain (N = 40).
| OUTCOME MEASURE | FOLLOW-UP AT 1 MONTH |
|---|---|
| Pain Level | Reduced = 92% (n = 37)
Same = 8% (n = 3) Worse = 0% (n = 0) |
| Satisfaction | High = 52% (n = 21)
Moderate = 38% (n = 15) Low = 10% (n = 4) |
| Complications | 8% (n = 3) included some mouth soreness and difficulty sleeping |
| Exercise Compliance | High use = 68% (n = 27)
Low use = 32% (n = 13) |
Early diagnosis, these clinical guidelines, and proven products to reduce acute jaw sprain or strain make all the difference.
What is the Jaw Parafunction Risk Rating Protocol?
The Parafunction Risk Rating Protocol was developed by Drs. Eli and Brady to help dentists accurately assess parafunction for treatment planning and patient awareness. Not all parafunction is associated with a TMJ disorder, and the simple grading system helps you educate and engage your patient in their bruxism condition.
Within the medical and dental profession, few clinical techniques and protocols related to the treatment of jaw joint and muscle sprain/strain exist. Our team’s work promotes the recognition of the prevalence of jaw injuries, patient risk factors, and associated preventative measures. The awareness information and treatment techniques outlined in our protocols are designed to assist dentists in reliably providing conservative and appropriate care when a jaw injury occurs.
Watch this video as Dr. Brad Eli discusses his training and clinical experience in orofacial pain and the need to develop treatment for acute jaw and muscle sprain/strain.
Clinical Protocols Conclusion
Above we have outlined the specific treatment protocols to address a currently unmet need in the diagnosis and treatment of temporomandibular joint disorders. This information is equally timely as the March 16, 2020, NASEM Consensus Report outlines this healthcare treatment shortcoming. By utilizing these easy-to-institute clinical protocols, dentists and healthcare professionals can address acute temporomandibular disorders with an easy and direct treatment. Our experts have found them effective in reducing the development of chronic pain.
When experiencing jaw joint and muscle strain/sprain, it’s important to take early action that will encourage rapid healing to resolve pain. Orofacial Therapeutics’ clinical protocols can help patients and their healthcare providers to mitigate risk factors that can delay recovery.
Author bio
Dr. Brad Eli, DMD, MS is a graduate of UCLA’s post-doctoral Orofacial Pain program. The field of orofacial pain, temporomandibular disorders, and treatment of sleep disorders became the 12th specialty of dentistry in 2020. Over the past 29 years of clinical practice specializing in orofacial pain and sleep, Dr. Eli has also been on the educational staff at university hospitals, pain centers, and the clinical staff of Southern California hospitals
References
[1] Valesan LF, et al., Prevalence of temporomandibular joint disorders: a systematic review
and meta-analysis. Clin Oral Investig. 2021; pubmed.ncbi.nlm.nih.gov/33409693/
[2] Gary M. Heir, DMD, Orofacial Pain, the 12th specialty, Commentary, Journal of American Dentistry, p.469, 2021; jada.ada.org/article/S0002-8177(20)30360-3/fulltext
[3] Dislocation and sprain of joints and ligaments of head, Updated 2022; icd10data.com/ICD10CM/Codes/S00-T88/S00-S09/S03-/S03.4 and nap.nationalacademies.org/read/25652/chapter/5#83
[4] Overview of Recommendations, Temporomandibular Disorders: Priorities for Research and Care, 2020; nationalacademies.org/news/2020/03/jaw-disorders-are-common-but-care-is-fragmented-and-evidence-based-approaches-are-needed-says-new-report
[5] Fricton, DDS, et al., 2021; doi.org/10.1016/j.adaj.2021.11.013