S.A.F.E. Protocol Instructions

S.A.F.E Protocol Instructions for Preventing JAMSS Injuries During Dental Procedures

Preventing JAMSS Injuries During Dental Procedures

By Ann McCulloch | Edited by Bradley Eli, DMD, MS

The S.A.F.E. Protocol provides pre-treatment guidance to help dental professionals prevent and reduce Jaw Joint and Muscle Sprain/Strain.

In this article we outline simple steps that can easily be incorporated in dental practices to promote patient safety and minimize the risk of injury. Our S.A.F.E Protocol instructions reduce risks from hyperextension of the jaw during long dental procedures.

A little soreness in the jaw after a dental procedure is common, and most cases will resolve on their own. But for about 20 – 25% of patients, jaw pain won’t resolve normally. These patients are at a higher risk of developing a jaw and muscle sprain/strain (JAMSS) from a dental procedure.

Orofacial Pain Specialist, Bradley Eli, DMD, MS, regularly sees patients with chronic temporomandibular disorders in his practice. From initial symptoms of jaw soreness and limited range of motion, symptoms can increase, expanding in scope-of-pain to include headaches, earaches, neck pain, and jaw dysfunction, such as clicking and locking.

Dr. Eli, together with Orofacial Pain Specialist and educator, Dr. James Fricton, and educator Dr. Lee Ann Brady have developed the S.A.F.E Protocol Instructions to preventing JAMSS injuries during dental procedures. The objective of this protocol is to help dental offices identify higher risk patients and/or higher risk procedures and prepare in advance to maximize patient comfort. The Protocol should be shared with all staff, intentionally including the front desk personnel, dental assistants and even treatment coordinators.

Jaw Joint and Muscle Sprain/Strain (JAMSS) is a Diagnostic Term

Jaw Joint and Muscle Sprain/Strain (JAMSS) describes an acute trauma to the jaw joint or muscles. JAMSS is characterized by sudden onset acute jaw pain, limited range of motion, tenderness or dysfunction. It is defined as a localized, acute musculoskeletal disorder caused by traumatic or mechanical injury or both.

Sudden onset acute pain associated with JAMSS refers to a patient with no prior history of jaw pain or treatment for dysfunction. It is common for both muscle strain and joint sprain to coexist; therefore, it is not essential to differentiate for initial treatment of JAMSS.

JAMSS is a common sequalae to dental procedures.

Trauma during dental care may occur as a result of local anesthetic injections, hyperextension from opening the mouth too wide or for too long a period or placing excessive force on the jaw during a dental procedure. Procedures such as mandibular anesthetic blocks, crown preparations, endodontic procedures, dental extractions, periodontal surgeries and others can sprain the temporomandibular joints and/or strain the jaw muscles leading to JAMSS. Patients with temporomandibular disorders (TMDs) often report that the initial onset of pain was a direct result of dental care. [1]

Initiating factors of JAMSS:

  • Direct trauma to the jaw muscles or joints (including injections).
  • Sustained or forceful contraction of the masticatory muscles.
  • Hyperextension of the masticatory muscles and temporomandibular joints.
  • Prolonged stretching of the masticatory muscles and joints, ligaments, and tendons
  • Resting (finger rest) on the patient’s mandible can push the jaw open and creates a risk of hyperextension of the related muscles and TM joint.

What are risk factors associated with JAMSS?

Risk factors for JAMSS also may include behavioral, emotional, cognitive, and social risk factors. When this is present along with a pre-existing history or comorbid conditions can result in the progression to chronic persistent pain. Additional considerations are pre-existing TMD symptoms, limited range of motion (if the patient’s voluntary jaw opening is less than 30 mm), the location and type of procedure, duration of the procedure, and type of anesthesia all factor into the risk for JAMSS injury.

Refer to the S.A.F.E. Protocol – Procedure Risk Assessment Table to identify and manage higher risk procedures. Recent studies have shown.

“High-impact TMD cases had 5.5 greater odds of experiencing jaw pain fluctuations relative to low-impact TMD cases, indicating that short-term jaw pain fluctuations may be at least partially associated with greater impact for TMD pain,” according to Alberto Herrero Babiloni, a member on The American Board of Orofacial Pain. The January, 31, 2022 Temporomandibular Disorders Cases with High-Impact Pain are more likely to Experience Short-term Pain Fluctuations article discusses how better TMD treatment strategies may lead to improved quality of life for this patient population.

Risk Factors Associated with Jaw Joint and Muscle Sprain/Strain
Risk Factors: Examples:
Behavioral Repetitive oral habits, muscle tension, jaw postural habits, diet, sleep, smoking, recreational drug use
Emotional Anxiety, depression, fear
Cognitive Poor understanding, unrealistic expectations, coping strategies, catastrophizing
Social Lack of social support, secondary and tertiary pain, conflict, abuse
Comorbid conditions associated with chronic persistent pain Fibromyalgia, migraine, back pain, other chronic pain conditions, history of acute jaw pain or injury

How do Jaw Muscles Function?

The jaw muscles assist the jaw’s complex three-dimensional movements. The physical makeup of the masticatory muscles reflects the type of activity required. Jaw muscles work to open and close in coordination with the cerebellum in the brain. The jaw muscle sequencing of opening and closing is “rhythm pattern generated”. Consider this pattern the harmonized motion of the jaw.

When the openers are engaged, the closers are silenced. When the jaw is strained, the lateral pterygoids (jaw opening muscles) fatigue, the opener/closer muscles fire out of sequence. The jaw closing muscles are the masseter, temporalis and medial pterygoid.

When jaw muscles get overstretched, the natural rhythms are interrupted and protective muscle guarding is often triggered, causing a state of sustained contraction and hypertonicity. Temporomandibular joints and associated muscles, tendons and ligaments are in continuous use and are difficult to immobilize for healing.

The surface tissue of the jaw joints is made up of fibrous-connective tissues. They make the TMJs more resilient and able to repair because the fibrous connective tissues can regenerate. Normal recovery from JAMSS is two to four weeks. However, pain and dysfunction can be a stressful experience for a patient if they are not mindful of risk factors for re-injury or if they are not mindful of self-care measures to enhance recovery.

What is the S.A.F.E. Protocol?

This protocol is a pre-treatment protocol to help dental professionals prevent and minimize JAMSS injuries during dental treatment. The protocol is based on an orthopedic model of care. It recognizes the unique characteristics of the jaw joint and facial musculature. These steps complement the JAMSS Protocol a comprehensive care plan to evaluate and manage acute jaw joint and muscle sprain/strain injuries over a 2 to 4-week period.

S.A.F.E. stands for:

  • Set-up for safety.
  • Assess risk.
  • Follow protective measures.
  • Evaluate the patient post discharge.

This protocol should be available to all dental professionals

Every team member needs to understand what JAMSS is, how it happens, and have the systems in place in the office for prevention and management. The S.A.F.E. Protocol documents are made available free of charge to all dental professionals via quicksplint.com courtesy of Dr. Eli and Orofacial Therapeutics, LP.

S – Set-up for Safety

a. Educate your dental office team about the risk of Jaw Joint and Muscle Sprain/Strain (JAMSS) injuries. Make sure everyone in your office, from the person answering the phone, who might take the post-op call, to your clinical staff of hygienists and assistants, need to know what JAMSS is and why speed-to-treat is important to prevent JAMSS injuries from progressing to a chronic pain condition. Demonstrate how you will screen for risk on a pre- and post-op basis, and how acute JAMSS should be treated using the JAMSS Protocol.

b. Create patient education information on JAMSS to include in your digital signage, patient education materials in your waiting room, informed consent, and post-op instructions. Patients understand sprain/strain conditions for other joints and will relate to this concept as distinguished from other more chronic or complex orofacial conditions.

c. Educate the patient prior to the procedure so that any post-op symptoms are not ignored and are identified and responded to promptly. Patient education about JAMSS should become a part of all pre-op and post-op patient instructions.

A – Assess Risk Associated with Patient and Procedure

Dental procedure risk assessment table for S.A.F.E protocol

a. Educate your team about the risk of Jaw Joint and Muscle Sprain/Strain (JAMSS) injuries. Make sure everyone in your office, from the person answering the phone, who might take the post-op call, to your clinical staff of hygienists and assistants, need to know what JAMSS is and why speed-to-treat is important to prevent JAMSS injuries from progressing to a chronic pain condition. Demonstrate how you will screen for risk on a pre- and post-op basis, and how acute JAMSS should be treated using the JAMSS Protocol.

b. Create patient education information on JAMSS to include in your digital signage, patient education materials in your waiting room, informed consent, and post-op instructions. Patients understand sprain/strain conditions for other joints and will relate to this concept as distinguished from other more chronic or complex orofacial conditions.

c. Educate the patient prior to the procedure so that any post-op symptoms are not ignored and are identified and responded to promptly. Patient education about JAMSS should become a part of all pre-op and post-op patient instructions.

d. If you identify a specific risk for JAMSS such as limited range of motion or prior history during your assessment, it is recommended that you fit the patient with a QuickSplint interim oral appliance for overnight wear and schedule a follow-up appointment in 2-4 weeks for an Extensive Evaluation. Use either the JAMSS Protocol or the Parafunction Risk Rating Protocol to help alleviate symptoms and gain diagnostic insight. The follow-up appointment should be documented and billed under D0160, as an Extensive Evaluation.

f. – Follow Protective Measures. The extent to which protective measures are followed should be customized according to the reasons for which the patient is in a specific risk category. For example, the use of certain dental technologies, materials and techniques may result in longer treatment times and the need for staged treatment. The more comprehensive the restoration plan, the more likely the patient could experience some level of JAMSS due to frequency of care. Special consideration must be made for appointment lengths and the frequency of breaks for jaw relaxation.

For high-risk patients and/or special needs patients, the following measures can be implemented on the day of a dental procedure to decrease the risk of JAMSS injury:

  1. Schedule intentional time for breaks during the procedure.
  2. Avoid opening the patient’s mouth too wide or for too long a period.
  3. Minimize fulcrum pressure during operative work.
  4. Never force the jaw open.
  5. Limit the use of bite blocks that keep the mouth open for longer periods of time.
  6. Make a QuickSplint before the procedure for use by the patient during breaks.
  7. Avoid multiple injections to achieve anesthesia. If multiple injections are used, the use of the JAMSS Protocol (providing a QuickSplint post-operatively) could be used to prevent trismus and acute strain.

E. – Evaluate the Patient Post Discharge

After the appointment, it is helpful to call within 3 to 5 days and ask a higher risk patient if they have any pain in the jaw, temples, or joint, documenting symptoms that might indicate the presence of JAMSS. Schedule a follow-up appointment and conduct a post-treatment assessment for Medium and High-Risk patients using the same patient evaluation steps described previously.

Perform a patient examination to check for acute JAMSS symptoms. The examination should take no longer than 2-3 minutes and include the following.

Post discharge Evaluation:

  • Range of motion (compare to pre-op measurement).
  • Joint sounds.
  • Signs of bruxism.
  • Joint and muscle tenderness.

2 Situations to Consider Implementing the JAMSS Protocol:

  1. If the patient presents with pain and/or tenderness in the muscles or joints and/or limited range of motion (a decrease from the pre-treatment ROM measurement).
  2. If the patient has a prior history of complications or showed signs of jaw fatigue during surgery.

“High-impact TMD cases had 5.5 greater odds of experiencing jaw pain fluctuations relative to low-impact TMD cases, indicating that short-term jaw pain fluctuations may be at least partially associated with greater impact for TMD pain,” according to Alberto Herrero Babiloni, a member on The American Board of Orofacial Pain. The January, 31, 2022 Temporomandibular Disorders Cases with High-Impact Pain are more likely to Experience Short-term Pain Fluctuations article discusses how better TMD treatment strategies may lead to improved quality of life for this patient population.

In December 2017, NIH Researcher Maria V Tan quoted estimates in the TMJ DISORDER document suggesting that over 10 million Americans are affected by TMJ pain; that number is believed to be pushed higher today by COVID and other economic pressures. Meaning, that if the S.A.F.E. Protocol is used earlier on, it may benefit a significant number of individuals.

Summary: S.A.F.E. Protocol Instructions

Orofacial pain specialists regularly see patients with temporomandibular disorders who indicate that their symptoms started after a common dental procedure. Patients are accustomed to calling their dentist if they have tooth or nerve-related pain. Less common, patients call with lingering jaw muscle pain or disability. Often patients wait too long to pursue treatment, or instead visit a medical provider.

In addition to these S.A.F.E Protocol Instructions, Orofacial Therapeutics has developed practice aids and patient flyers for dental offices to use. Other helpful products to assist with patient comfort during long dental procedures are the Restful Jaw®, the Helping Hand® and the gentle jaw®. We enjoy hearing your suggestions and encourage you to contact us at ann@orofacialtherapeutics.

 

Author bio

Author Dr. Brad EliAnn McCulloch, MBA is co-founder and president of Orofacial Therapeutics, this site, and oversees the company’s expanding portfolio of resources and tools for jaw and headache pain diagnosis and treatment. Her chronic jaw pain issues continue to inspire her to investigate the needs and challenges of patients suffering from orofacial pain.

 

References

[1] Brady LA, Fricton J, Eli B, Postoperative Jaw and Muscle Pain, a guide to risk assessment, prevention, and treatment. Inside Dentistry. April 2017 69-76

[2] Fricton, James et al. Preventing chronic pain after acute jaw sprain or strain. The Journal of the American Dental Association, Volume 147 , Issue 12 , 979 – 986

[3] Fricton J, et al. Myofascial pain and dysfunction of the head and neck: a review of clinical characteristics of 164 patients. Oral Surgery Med Pathology. 1985;60(6):615-623

[4] Gatchel RJ, et al. Efficacy of an early intervention for patients with acute temporomandibular disorder-related pain, a one-year outcome study. JADA, vol.137 March 2006 pp 339-3



n. 2011;152(3 Suppl):S2–S15.