JAMSS Protocol Instructions for Healthcare Professionals
Suggested as a universal standard of care when treating Jaw Muscle Spain & Strain
What is the JAMSS Protocol?
Our JAMSS Protocol instructions are a treatment plan to manage and evaluate acute JAMSS.
The JAMSS Protocol is a comprehensive care plan to manage and evaluate acute jaw joint and muscle sprain/strain over a 1 to 4-week period from injury or symptom onset. Normal recovery for a patient with no prior history of a temporomandibular disorder (TMD) is several days to several weeks to fully relax the jaw and return to normal function. Additionally, the protocol stratifies results and provides the practitioner with a clearly defined path for the next steps in care. Extensive training in TMJ disorders is not required for implementation by front-line care providers.
Recent research and clinical experience have shown that the best approach to encourage rapid healing with most sprain/strains in first- and second-degree injuries is a protocol that includes movement, exercises, analgesia and conservative treatment. The JAMSS Protocol, developed by orofacial pain specialists, is an orthopedic model of care that recognizes the unique characteristics of the jaw joint and facial musculature and bridges a current gap between medicine and dentistry.
Unlike a sprained ankle or knee which can be rested, the temporomandibular joint region is difficult to immobilize. Temporomandibular joints, muscles, and ligaments work together to make many different movements, including a combination of rotating and gliding actions used when speaking, chewing, and swallowing. Multiple nerves run throughout the jaw joint system, including the trigeminal nerve which is responsible for sensation in the face and the functions of biting and chewing. Any problem that prevents this complex system from working properly may result in a painful TMJ disorder.
The objectives of the JAMSS Protocol
1. Guide patients through an easy-to-understand care plan designed to break the cycle of pain.
2. Reduce the anxiety and discouragement associated with pain and disability by providing educational steps to help patients recover at home and without prescribed pharmaceuticals.
3. Raise awareness of the importance of early intervention to prevent the progression of protracted pain, and the availability of simple cost-effective treatment.
4. Facilitate your differential diagnosis and promptly identify patients who should be referred for further examination and care from a specialist.
JAMSS Protocol Specifies Use of a Multimodal Treatment Strategy
These are conservative interventions to be tried during a two-to-four-week recovery period. Modify this care plan as appropriate to your practice and your patient’s unique condition.
1. Temporary oral appliance: use primarily for overnight wear. The type of temporary device is called an anterior bite plane splint. The objective of this type of oral device is to facilitate joint unloading and masticatory muscle relaxation by inhibiting posterior occlusal contact of the molars. Anterior bite plane splints are typically “permissive”, allowing the jaw to find its most comfortable resting position. This appliance design, delivered as soon as possible, provides an interference in jaw and upper cervical muscle contraction and guarding.
2. Thermotherapy and Cryotherapy: cold therapy decreases circulation to the injured region and reduces inflammation and muscle tension. Thermotherapy increases circulation and oxygenation and elimination of metabolic waste. Heat therapy promotes muscle relaxion and the reduction of the guarding reflex.
3. Exercises: for acute injury, early mobility is important for the interruption of peripheral sensitization. Gentle exercises of the jaw and tongue facilitate pain-free mouth opening and reduction in daytime clenching behaviors.
4. Supportive self-care measures: goal-based directed self-care pathways using small and realistic accomplishments that can be achieved over time when coupled with the start of treatment with these other measures is beneficial for patients to experience momentum and expectation of a positive treatment outcome (and is thus more inclined to continue treatment.)
Initiate the JAMSS Protocol Immediately
The time between the onset of jaw and neck musculoskeletal sprain/strain symptoms and the initiation of specific care can be a contributing factor to chronicity. If not addressed within the first 30 days, injury to jaw joints and muscles have a greater than 50% chance of progressing to progressive or intractable pain. [1-2]
Clinical protocols for early intervention can reduce pain amplification to the central nervous system by down-regulating multiple pain pathways. Therefore, the JAMSS Protocol should be instituted as soon as possible to minimize the impact of patient suffering and improve the likelihood of success in reducing dysfunction, and/or progression to a chronic pain condition. Clinical experience shows that 60% or more of patients with JAMSS (without significant prior history) who enter a speed-to-treat model will improve within four weeks to normal jaw function, where the patient is compliant.
Jaw joint and muscle sprain/strain are typical noninfectious complications in dentistry. “If jaw pain is treated within a week, the chances of it healing successfully within four weeks is much greater,” according to Lara James, RDH. The Sep 16, 2021, Jaw sprain or jaw strain symptoms and treatments article points out that people who missed early treatment report pain years after the initial injury occurred. Jaw joint and muscle strain/sprain isn’t rare but it’s often underreported, misdiagnosed, and misunderstood.
Steps in The JAMSS Protocol
Step 1: Initial evaluation.
Step 2: Diagnosis.
Step 3: Deliver temporary oral appliance for overnight wear.
Step 4: Patient education on self-care measures.
Step 5: Follow-up Appointment at 1 week.
Step 6: Follow-up Appointment at 4 weeks.
Step 1: Initial Evaluation
a. Have the patient complete this Questionnaire to evaluate risk factors associated with JAMSS. Any “yes” answers suggest there is some risk of jaw joint and muscle sprain/strain.
| JAMSS Risk Assessment Questionnaire | |||
|---|---|---|---|
| 1 | Do you often have jaw or facial pain? | YES | NO |
| 2 | Do you often have headaches? | ||
| 3 | Do you have difficulty opening your mouth wide? | ||
| 4 | Does it hurt to chew hard or chewy foods? | ||
| 5 | Does it hurt after dental work is done? | ||
| 6 | Are your jaw and temple muscles tender when you press on them? | ||
| 7 | Do you often notice yourself clenching or holding your teeth together? | ||
| 8 | Do you often feel anxiety or nervousness? | ||
| 9 | Do you often notice yourself clenching or holding your teeth together? | ||
| 10 | Do you often feel depressed, downhearted or blue, due to pain? | ||
| 11 | Do you often feel anxiety or nervousness? | ||
| 12 | Do you often feel like you have had a lot of stress? | ||
b. Pay special attention to when their jaw pain started and any prior treatments for the current complaint. Note whether the patient has a prior history of jaw injury, treatment or other pain complaint.
c. Perform an initial examination to check for acute JAMSS symptoms. This should take 2-3 minutes.
- Range of motion (this should be documented at every appointment)
- Joint sounds
- Signs of bruxism
- Joint and muscle tenderness
Step 2: Diagnosis
If the patient exhibits any symptoms of JAMSS, and none of the exclusionary symptoms listed, the JAMSS Protocol should be started immediately.
| Symptoms of JAMSS | Exclusionary Criteria |
|---|---|
| Acute jaw, face, ear, and/or head pain | Presence of infection or cellulitis with redness, swelling, tenderness |
| Limited range of motion, less than 40 mm | Pericoronitis to partially impacted teeth |
| Tenderness of muscle and ligaments | Signs of fracture |
| Dysfunction (difficulty chewing, opening or closing mouth) | Bleeding and bruising in tissues |
| Inflammation with swelling and tenderness of joint | Open wounds or lesions in mouth or on lips |
| Localized pain to muscles and joint | Open jaw-locking (with shifting of jaw to the side to close it) |
| Closed jaw-locking (catching of jaw due to disk displacement) |
Note: Patients with a prior history of jaw injury can be treated with the JAMSS Protocol. If this type of patient presents in your office with jaw pain (a sudden flare-up or reoccurrence) provide a temporary oral appliance and encourage the use of the patient’s self-care measures. The patient’s pain and/or dysfunction may not resolve in four weeks. Referral to an orofacial pain specialist may be recommended for evaluation and care that might include imaging, medication, and/or integrative care by specialists.
Step 3: Deliver a temporary oral appliance to the patient for overnight wear.
An anterior bite plane splint, such as the QuickSplint®, is a conservative, non-invasive treatment modality that can help diagnose and manage the relationships between temporomandibular joint structures, jaw muscle activity, and neural control. For the JAMSS Protocol, the QuickSplint mouth guard is worn at night during sleep to reduce jaw closing muscle hyperactivity (e.g. jaw clenching or tooth grinding), inhibit muscle guarding, and help encourage healing of joint inflammation and restricted jaw opening. The flat occlusal surface allows the mandible to move freely in various directions instead of closing into a specific dental relationship. [5]
It is designed for temporary use to minimize occlusal changes and allow time for jaw mobility to improve. This allows for pain-free impressions to be taken if a long-term appliance is indicated. QuickSplint is not a substitute for indicated full-coverage splint therapy nor is it designed to avoid appropriate diagnostic imaging. As an initial step in treatment for jaw pain or parafunction, QuickSplint helps with patient acceptance of final treatment with a full coverage splint.
IMPORTANT: Direct the patient to call your office and discontinue the use of QuickSplint if pain worsens. If this happens, perform a detailed examination of the TMJ function, or refer to a dentist specializing in TMD or an orofacial pain specialist.
Advise the patient that a temporary dental deprogrammer should not be worn on a long-term basis due to the risk of super-eruption of the posterior teeth.
Step 4: Patient education on self-care measures
The patient should be directed in the following self-care measures that may be helpful in easing symptoms and reducing risk factors for chronic pain. Implied in this 4-week program is the notion that the patient needs to accept responsibility for their health and exhibit patience over a recovery period that could be 4 weeks, or in some cases longer.
a. JAMSS Patient Self-Care Measures
The JAMSS Patient Self-Care Measures are designed to provide patient self-care training on managing pain, daily jaw care, and how to avoid risk factors for delayed recovery. Careful use of the jaw will increase blood flow, encourage healing, and restore jaw function.
JAMSS Patient Self-Care Measures
Our JAMSS Protocol instructions include easy ways to take helpful self-care steps.
| Self-care is a Core Component of your Jaw Pain Recovery Process | |
|---|---|
| Heat, Cold & Massage | Apply moist heat and/or cold to reduce pain in tender muscles and joints. Generally moist heat is used for comfort and relaxation and cold is used in the first 24 hours to control swelling. |
| Exercises | Gradually increase your jaw range-of-motion by placing two fingers, then three fingers between your front teeth and hold for a count of ten. Perform this stretch four times per day. Exercise and stretch your jaw daily with the jaw exercises provided to you. Closely monitor your jaw position during the day so that you maintain your jaw in a relaxed, comfortable position. |
| Analgesics | Use anti-inflammatory and pain reducing medications. Short-term use of over-the-counter ibuprofen, naproxen, acetaminophen or aspirin (without caffeine) can reduce joint and muscle pain. It is important to control pain as soon as possible to improve jaw function. |
| Lifestyle |
Positive choices that promote healing of the jaw:
|
| Strain | Reduce muscle-tensing habits & activities that put strain on the jaw. • Clenching and grinding your teeth (bruxism) • Touching or resting your teeth together • Biting cheeks (may cause referred cheek bone pain), lips, or tongue • Eating or biting hard or chewy foods • Chewing gum • Resting your jaw on your hand • Straining the jaw when playing a musical instrument • Pushing the tongue against the teeth • Tensing your jaw or pushing your jaw forward or to the side • Opening your mouth too wide or too long when yawning, singing, or during dental visits. |
b. Jaw Exercises
Simple daily repetitive motion exercises performed throughout the day help stretch and rotate the jaw joint and restore normal function and range of motion. Jaw exercises should be performed at least 6 times per day for 10 seconds. It may take up to 7 days for a patient to experience the benefits of jaw relaxation since many patients will clench or brux during the day unconsciously.
Patient Instructions for JAW Exercises
These Jaw exercises are designed to help you avoid daytime clenching or the setting of teeth that causes your jaw and temple muscles to overwork and become sore. Masseter or jaw muscle soreness can be a trigger for headaches and/or jaw pain.
| Therapeutic Techniques to Relax Jaw Muscles | |
|---|---|
| 1 | Position your tongue gently on the roof of your mouth just behind your front teeth. To find this position say the letter “N”. |
| 2 | Holding your tongue in this position, rapidly open and close your jaw 10 times. Do not let your teeth touch when you close and do not open your mouth more than one finger in width. |
| 3 | Keep your tongue in position while you gently open your jaw as wide as comfortably possible. Make sure to keep contact between your tongue and the roof of your mouth while opening. |
| 4 | Then slowly begin closing until your lips come together and STOP, closing your jaws. This will be the resting place for your jaw, teeth, and tongue throughout the day. |
You should perform these four steps thirty or more times throughout the day for up to one week. Doing so will retrain your muscles and brain to relax your jaw in a comfortable resting position, keeping your teeth apart when you are awake. Jaw Rx-Ercises have been shown to have a positive effect on reducing jaw pain and headache.
Step 5: Follow-up appointment at one week
Evaluate the patient’s pain complaint, assess patient compliance with oral appliance therapy, review the exercises and self-care, and encourage the patient to continue diligently (unless their symptoms are resolved.) Examine the QuickSplint for bruxing marks which may indicate that the patient would benefit from a full arch dental appliance.
Determine whether the patient’s pain and/or jaw dysfunction is better, worse, or the same. If the patient’s pain is worse, discontinue the use of QuickSplint and refer to a specialist. If the patient’s pain is the same, be supportive and encourage the patient to continue self-care measures and use QuickSplint for an additional 3 weeks.
Schedule another follow-up in 3 weeks (unless pain resolves). Instruct the patient to bring the QuickSplint to the follow-up appointment so it can be examined for brux marks. If the patient’s pain resolves prior to this follow-up, they do not need further examination unless grind marks are present on the surface of the QuickSplint or you have discussed potential follow-up treatment for parafunction (prior to the acute injury event).
Step 6: Follow-up appointment at 4 weeks
Evaluate the patient and examine the anterior bite plan splint for clenching or grinding marks. Experience shows that 60% or more of the patients with JAMSS (without significant prior history) who enter a speed-to-treat model will improve within four weeks to normal jaw function. [2]
With a conservative, staged treatment that facilitates case stratification, it is easier to make a determination of medical necessity and adjudicate between dental and medical coverage.
JAMSS Protocol Patient Improvements
Patient results from following the JAMSS Protocol will be stratified into one of four groups:
1. Symptom resolution without the need for further treatment.
2. Symptom resolution with signs of simple parafunction (bruxism) which merits ongoing protection (splint therapy) to prevent irreversible damage to the hard-dental structure. Recommend patient evaluation by a dentist.
3. Improvement in symptoms, but signs of pathologic parafunction (bruxism) and/or continued symptoms. Depending on your level of training, you or a specialist should direct appropriate imaging, physical medicine, long-term splint therapy, and/or supportive care.
4. Non-resolution of pain symptoms or dysfunction, with the need for further examination (a problem more prolonged than a sprain/strain, persistent pain following a concussion, an intraarticular joint-related disorder, or other chronic pain condition.) These patients should be referred to a specialist for care that might include imaging, medication, and/or integrative care.
The JAMSS Protocol is available to all dental and medical professionals
Every team member needs to understand what JAMSS is, how it happens, and the systems in place in the office for prevention and management. The JAMSS Protocol documents are made available free of charge to all dental professionals via www.quicksplint.com courtesy of Orofacial Therapeutics, LP. Additionally, check out our S.A.F.E Protocol Instructions.