Tips and Tricks for Treating TMJ

I palpate the masseters and I look for trigger points. So I'm looking for those knots in the muscle. And then I will inject around those specific sites. I always do both sides the same. You know, you're not really going to make someone look funny if you relax the muscles on one versus the other. But just to be safe, you don't really want one side contracting way more than the other. And then if you do the temporalis at the same time, those muscles directly oppose each other with how they move. Welcome to the Phil Klein Dental Podcast. Amongst the top dental educators in the U .S., the prevailing opinion is, if you want to make sure your restorative work is going to last, you need to know about the entire occlusal system. And that, of course, includes the TMJ. So Dr. Vondrak sought out CE courses taught by TMJ experts, which have given her not only the ability to understand and diagnose TMJ disorders, but actually treat them. She starts with protective therapy and then, if necessary, proceeds with corrective therapy. Now, treating TMJ disorders in-house is not for every GP, but understanding the options for your patients is certainly the responsibility of the general dentist. To enlighten us on how to excel in diagnosing and treating TMJ issues in our general practice is our guest, Dr. Stephanie Vondrak. Dr. Vondrak owns and operates a private practice in Elkhorn, Nebraska. She has pursued over 600 hours of post-doctorate education in TMD, occlusion, orthodontics, and sleep apnea, and she has completed extensive training at the Panky Institute, the Schuster Center, and the American Academy of Craniofacial Pain. Dr. Vondrak will be joining us in a second, but first, as dental professionals, we want our crowns and bridges to be strong and beautiful, but it seems we've always had to sacrifice one for the other, until now. With prime zirconia, you get a revolutionary material that provides the strength for splints and bridges, and the superior aesthetics and translucency for anterior cases. Prime zirconia discs are made with a state-of-the-art gradient technology that creates Y3 strength where it's needed, as well as Y5 translucency for aesthetics. So thanks to Ivaclar, you can finally choose a material that offers the strength of zirconia and the aesthetics of lithium disilicate. That's why top clinicians around the world are prescribing prime zirconia to their labs. Your patients will be thrilled, and so will you. To learn more, visit ivaclar.com, or to locate a lab near you, Check out the link in the description. Dr. Vondrak, welcome to our show. Thanks so much for having me. So lots of dentists struggle with diagnosis of TMJ disorders. That's just the way it's been for years. I mean, I practiced a long time ago. I won't tell you when, but it's been quite a while since I was an endodontist. I had GPs struggling all the time because they weren't sure if it was TMJ pain or was number two or number 15, what's hurting them on chewing. And sometimes it took quite a lot of detective work to find out what the cause was. So can you give general practitioners, which is the majority of our audience and hygienists out there, a simple checklist of what to triage when a patient shows up for a limited exam and you suspect that the TMJ is the problem, But of course, the patient's in pain and you want to come up with something definitive. Well, good question. The first thing on my checklist is always to, you know, get an accurate history of when the pain started, how long it's been going on. If it's TMJ, typically the patient will be able to tell you that they've had these issues off and on for however long, right? The first thing I then do, because this is usually, you know, a shorter limited exam, right, is a percussion test. You know, if they're pointing to whichever tooth, then go around and just make sure that you're not having an actual tooth that stands out. And generally, you're not going to have that happen with a TMJ issue. So that helps you to just easily kind of negate a tooth. And you can take a PA if you want. So those would be the first couple of things. Get a good history and then do a percussion test to see if any tooth stands out. The next thing you can do is to just kind of check their range of motion. One of the things you want to identify right away in triage is that they don't have a disc that's fully displaced and they're quote unquote locked. So I usually have them open as wide as they can that doesn't hurt. And then if they can open as wide as they can, even if it's uncomfortable. And you're just making sure they can get past that 25 to 35 millimeter range. If they can only open to 25, 30, maybe even 35 millimeters, and they just, it's a sharp pain and they cannot open any further, there's a good chance that disc is completely displaced. And that's where you need to refer them to the oral surgeon. So after that exam and you determine or believe that the TMJ is the issue causing the pain, what do you tell the patient? So I tell them at that limited appointment, you know, it is kind of like, let's just make sure that we don't have something that like is critical to be treated right now. And then you can talk to them about their options of what they need to do to actually treat their TMJ. And I can talk about that in a minute. But what I tell the patient is if they can't get open wide enough, that there's a chance that there's an issue with that disc in their jaw joint and that the surgeon is going to take a look. And I generally tell the patient, don't worry, it's not a super invasive thing. Because as we all know, they're probably headed for an arthrocentesis would be the first thing that they would do, which isn't a super invasive procedure. And let me just add for our audience who may not be familiar with that procedure, arthrocentesis is a procedure where you aspirate out fluid from an inflamed joint and possibly following up with an injection of corticosteroids into the joint. Yes. But I let them know that that's kind of where we need to be to rule it out. Or in my office, since I'm more of a specialist with it, I order the MRI. Most general dentists aren't going to order MRIs. But, you know, if you do that, then you know definitively if they're locked or not. But that's typically kind of how I talk to them. Let's say they're not locked. They can open to 50, but it's just very painful. Then I'm going to, and their jaw is popping or clicking. Then they've got two choices. One, we can go the protective route. which would be making more of a bite guard or something like that to see if that calms the symptoms. Maybe a muscle relaxer for a couple of days. Or in my office, I have more of the corrective route. Let's figure out why you're having the TMJ problem. Really thoroughly diagnose that and then make a plan. So for me, that's a TMJ records visit, which is a 90-minute visit where I do all sorts of things to assess the health of the jaw joints. And on the MRI, are there any specific instructions that you give the radiologist as far as an MRI for the TMJ? Yes, there are. When I did my residency program through the American Academy of Craniofacial Pain, we had written out kind of a basic instruction to have with the institution taking the MRI. So I have kind of some standing orders at the two hospitals that do it in Omaha. But the one thing that you can put on the referral is they almost always, these patients are having headaches, which will help the patient if that's written down. But your suspicion is that they have a disc displacement without reduction because doing a TMJ MRI requires something called a coil that goes around the head. And it's different than if they do a TMJ or if they do an MRI to look at the sinuses or the brain, you will not be able to see the jaw joints on any of those MRIs. So it has to be specifically for the jaw joint. And specifically what I write down is suspicion of a disc displacement without reduction. And there's no contrast involved with that MRI. Generally, no. Yeah, generally, no. Okay. So we all know as healthcare providers how important it is to take a good dental history, a good medical history. We learned that early on in dental school and med school. So tell us specifically why a good history... important in diagnosing TMJ disorders and moving forward with therapy. So when it comes to history, that's why those questions are really important. There's a large portion of the literature that's going to say, especially if it's acute, like all of a sudden their jaw, they just can't open. They possibly had whiplash. They had like a car accident or had some sort of trauma that happened because there's a large part of the literature that talks about traumas related to those issues. Or they've had a very chronic problem where they've had instances where they kind of got stuck but were able to get themselves unstuck. They just can't get unstuck. this time. So it's not that common to have a TMJ patient just get stuck out of the blue for no reason, right? It's either that they've been dealing with it and compensating or something happened to induce it. That's why I always start with that good history first. If the jaw is still popping and clicking, that cartilage is moving. It's not moving in coordination with the bone, but it's moving. That's something you can then treat in your office. Let's talk about the difference between protective TMJ appliance mouth guard and a corrective TMJ splint. And I know you covered it just briefly just now. And what do you start with in your practice? Sure. So if you're a general practitioner listening to this and you're like, well, I don't want to just send all these patients out that are having these issues. It's not wrong to start with a protective appliance. Given my education, I generally move right into that records, but those patients are prepared because they found me for that. So if you're a general office and the patient's jaw is bothering them, it's not wrong to tell them, hey, let's start with a mouth guard and see how you do. But that way they're prepared to know that might not be their final answer, but it's a good place to start. So a protective mouth guard is what we're taught in dental school. If I do one, I typically do a thermal flex appliance, which is where there's a little bit harder material on the outside and a softer on the inside that you go under the warm water. I always make sure they have canine guidance and protrusive guidance and that they're not hitting too heavy on their second molars. And that's one place that you can start. One of the times that I'll use that is if someone has popping or clicking or someone has slight pain in the morning, but it's really not, they're not a quote unquote TMJ patient. They're just noting slight discomfort. They're not like a chronic pain type patient. That works well. If it's not enough, then you can move to a corrective splint. So corrective splint is something in which I reposition the mandible to where I can a lot of times reduce the disc on my own. What that means is if you can get the patient to a position where their popping and clicking goes away and keep them there and make a splint to where they stay in that position and that disc is reduced, they can get some healing. Yeah. Is that corrective splint worn all day and night? Yes. 24-7, you eat in it, you sleep in it, you wear it to work all the time. So I'm cautioning that's not something you want to do unless you've had that advanced training. because it's going to change their bite. Like there's going to be a phase one, we correct and reduce the disc and get the jaw relationship correct. Then we get the teeth to fit in that corrected position. So that's definitely a continuing education, have to know how to do that. So a lot of times when I'm lecturing and I'm talking to patients, or I mean to doctors, I can see them looking at me like, well, I don't refer out every one of my patients. And I'm like, don't. talk to the patient so they know protective is a good way to try let's see if it takes care of it because if it takes care of your symptoms fantastic let's move on right but if it doesn't then you can find someone who knows how to do corrective tmj therapy because it's really involved those patients have to have a really strong need because that's a lot of work usually they're in that split for six months where they're wearing it 24 7. so you're not going to do that unless you really need it so in the case where the gp tries the protective, doesn't work, they need to send the patient out, who would you recommend they send to? Because as far as I know, I don't think there's a specialty in itself related to the temporal mandibular joint. Am I correct? There's not. I think there should be, but there isn't. If you can find someone who's been to the AACP, the American Academy of Crane and Facial Pain, that's a really good one. But I would say look in your local area on websites and see where some of those doctors have trained. Because there's places that teach, Tufts has a good school where they teach some of this, that has a relationship with the AACP. There's several of them out there. And so I would look for... other doctors in your area that seem to have some of that advanced training. Regarding the protective mouth guard, can that be fabricated in the office using 3D printing? Or is that something that's primarily sent out to an outside lab? You know, maybe you can. I don't have a 3D printer in my office. So if I'm making a Thermoflex protective guard, that is made at a lab. Interestingly, I was taught how to do this. If I'm making a corrective splint, I make those myself. And I start with the powder and the liquid acrylic and I bend my orthodontic clasps and I make the whole thing. But then I know it's exactly how I want it. Now I have a whole nother level of respect for you, Dr. Landry. Because I do remember in dental school when I went to Penn, we created these retainers and bending the wire was the most difficult thing I think I... ever done in dental school way harder than doing a number two retreatment of a molar because every time you bent it and you thought you had it right it's three-dimensional obviously and you've got two dimensions perfect and then the third one is off and you fix the third one and then the first one is off does that sound familiar It does. Doing these little clasps to get retention on the poster teeth isn't nearly as tricky as that, but I do know what you're talking about. I've got some really great trained assistants that can practically make them on their own. It's fun. Actually, people kind of... fight over who gets to make them because it's kind of fun to do. So, but you have to mount models and do all of that. So again, a lot of doctors aren't wanting face bows and things like that. But I think that's a good way to just kind of help people to get nervous about TMJ. It's not wrong to offer something protective. You just have to make sure the patient knows that just could be a starting point. You know, where people get upset is if they think that's for sure the final answer. And these are human bodies that we're dealing with. We'll be right back with Dr. Vondrak in a moment, but first, we all know that to achieve healthy, beautiful smiles, we sometimes need to align the teeth. And to do so, aligner therapy is a great option. So why not set your practice apart with 3M Clarity Aligners Flex. Designed for comfort, Clarity Aligners Flex feature a thin, flexible design. yet they deliver excellent force persistence over a two-week period. Plus, they resist scratching and stains, and they're backed by a dedicated clinician team providing support every step of the way. With a variety of affordable case-type options, single or dual -arch, Clarity Aligners Flex offer a great value to your patients and practice. To learn more, visit 3M.com slash clarity dash aligners dash flex. So out of curiosity, Dr. Vondrock, what drove you to become somewhat specialized in TMJ disorder, getting that extra training, that continuing education training at the American Academy of Craniofacial Pain? So I am just one of those people that I don't like not knowing things. Right. I love to learn. I love to read. I love to I am very interested to always know more. But I'm also very interested that the dental work I do work really, really well. I don't want failures. And so I felt like at some of these institutions, I learned how to do really great restorative dentistry. But it's like we never actually talked about the jaw joints. And so then, you know, if you have something break or chip, when I started dentistry, we're still doing those Empress crowns. Remember those? They broke like crazy. And so if you want to make sure that your work's going to last, you got to know everything about the whole system. And so I felt like I had to really understand. that part to do good restorative. And then I found I really liked, you know, helping get people out of pain and making these splints and doing these things. Did your training, your advanced training after dental school begin with occlusion, the additional occlusion training that you got? Because my impression, and I'm an endodontist, so I'm not an expert on this, but to me, understanding the occlusion, and that's, I'm an old friend of Dr. John Coyce. He always felt that in order to be a good dentist, you have to really master the whole concept of occlusion before you could get into restorative dentistry or anything else. Totally accurate. Yes. And I really feel like dental school teaches you how to restore a tooth as if it's its own standalone entity. They don't really get into how the whole system works well. And it's just hard to do all of that in four years. I just think it's nearly impossible. And so I felt when I graduated that I didn't fully understand how the system worked. And that was at the time when Extreme Makeover was on television and everybody wanted veneers. And you want to talk about if you don't know how to do occlusion, you decide to do a whole bunch of veneers, you're in big trouble. right? So I just knew I needed to know more. And so the more I learned about one led me to the next thing I needed to learn, which led me to the next thing I needed to learn. And that's kind of how, you know, I ended up with this type of education. There's no question. It's so important to understand the whole system, the whole system of occlusion. And I remember when I first started as an endodontist, I saw cases, the patients would come in, open their mouth, and I would, it looked like every single tooth in their mouth was done by a different dentist at a different time in a different country. I mean, the materials were different. They were just bizarrely positioned in the mouth, detrimental to their occlusion. I guess there were limitations on finances or whatever reason. It was more of an emergency-based treatment, which is tooth dentistry. And that's just the opposite of what we're talking about here. So there's another thought I want to talk about with TMJ, and that's Botox. I've heard about Botox possibly helping. with not only TMJ, but also headaches. But since we're talking about TMJ, how does Botox play a role in this? Sure. So headaches are obviously one of the symptoms that can come with having a TMJ disorder. And so when you're doing that diagnosis, you're identifying what a patient needs. If they don't have a lot of popping or clicking, or any for that matter, but they still have pain, then you can surmise that it's more of a muscular source of a problem. than an orthopedic in the sense, you know, you can assume the disc is probably in an okay position if that's not the issue. So if they're having a muscular issue, Botox is extremely effective. So what I typically do is I don't like Botox to always be the only source of treating the problem because then they're always going to need Botox, which is expensive. right, for patients long term. But it's a really good adjunct to get them out of pain quickly. Or sometimes I have patients that only need it like once a year and then they do fine with it. How I was trained is that I palpate the masseters and I look for trigger points. So I'm looking for those knots in the muscle. And then I will inject around those specific sites. And I'll do, I always do both sides the same. You know, you're not really going to make someone look funny if you relax the muscles on one versus the other. just to be safe you don't really want one side contracting way more than the other so you do both sides it's always bilateral and then if you do the temporalis at the same time those muscles directly oppose each other with how they move right so that helps and so you're going to get also the effect of decreasing headaches when you're calming down the trigger points in the temporalis so that's how i have found it to be the most effective in my office so with the use of botox you're assuming that the source of the pain is the muscle not necessarily the joint. I would look at it as this. TMJ can be a structural functional issue that causes the muscles to hurt. or the structural functional can be okay, but you still have a muscular problem. So TMJ can be diagnosed in lots of different ways. So if your source of pain, which is headaches, masseters are sore to the touch, waking up feeling like you've just been racing around with your jaw all night, but it's the muscles that are having the most symptoms, then you're just treating those muscles for that TMJ patient. If they're having a neurological issue, that's more like trigeminal neuralgia or something like that. That's a totally different topic or a long conversation. But I would look at TMJ as you have to kind of break down where you think the source is coming from. Is it the structure and function of the disc or is it just purely muscle? Because basically all TMJ patients are going to have sore muscles. But if that's their main problem only, then Botox is awesome. So does Botox help you? also with the diagnosis based on the response of the patient to the Botox? It can. It can. In my office, because people come to me for TMJ, a lot of times I'm using Botox as an adjunct. So let's say I get them in their corrective orthopedic position in their splint, but they just are miserable because they've been miserable for so long. Well, let's calm down those muscles just from the get-go for now so that you can start getting some relief as we get your jaw position correct. if that makes sense yeah so i don't you know i don't i don't use it as its end -all be-all or if i have someone who says i cannot afford splint therapy i just can't but i can i can afford this much for some botox injections now can i try that for a while until i can possibly do more later Absolutely. You want to help people feel better. Right. So that's definitely palliative. But when you see a case where the occlusion is just so jacked, I mean, it's an adult patient and it's just really jacked occlusion. Are there instances where a corrective TMJ splint would not be the answer? You would need something more definitive to do and some specialists would have to do something maybe surgically. Do you see those kinds of cases? You know, there's a couple of patients every year that we need some surgery on that we can't fully. correct. But what I would say is my practice is just a lot different because once I get them through that corrected position, a lot of times their back teeth don't touch or the problems in their occlusion are very obvious. Then you might have to do a lot of restorative dentistry to get their jaws to stay in that relationship. OK, so there's still a lot of sometimes I have to get the disc back where it's supposed to be with TMJ and then do a full mouth rehab. That happens. Or sometimes I do orthodontics, too. So sometimes I move the teeth where they need to be. But the whole idea of just kind of understanding the two differences for the general office is that protective versus corrective. But yes, once you get them stable in that correct position, there's always something more that needs done. The bite will be balanced at the end of that for them to maintain that position. So for a general dentist to get the training they need to handle probably the bulk of TMJ problems, which would be potentially treated by protective and corrective splints, mouth guard on the protective side and a splint for the corrective side. How much additional training does a general dentist need to actually, you know, define themselves as a practice that could confidently treat these TMJ issues like you are? It's a lot of training, I'll be honest, because it's tricky. That's where I think having an actual dedicated specialty would be very helpful for patients and doctors because there'd be more of a set curriculum. So, you know, I've kind of, you know, pieced my education together by being lucky to be around really amazing dentists and find different avenues. But I would say to get to that corrective side, you are going to have to really dive into a COIS or a SPEAR or go to the AACP. or go through one of these programs where there's several continuums to get to the end to understand how to do some of that. And so if you're like me and you're one of these people that really just hates not knowing things, just get on a journey and go. And you'll be able to come across some of that. But if you're like, you know what, I just want to be a basic general dentist, then start with the protective. You can even get trained on Botox because it does help people feel better for a while. And then just let them know if that's not enough, there are people out there that know how to do more. Yeah, I think that's fantastic that you're exploring new areas of, not new areas for you, but more specific niches of dental care. It's all part of the head and neck. That's what we've been trained in. A lot of dentists stay within their purview of teeth and gums, the attachment apparatus, as far as GPs go. But you're a GP and you've moved on to subspecialties. within the GP world, which I think is really honorable and very admirable actually. So, and I think it's a great practice builder and I think it gives you so much career satisfaction out of all this. Thank you very much, Dr. Vondrak. We really appreciate talking to you and hope to have you on the show again soon. Sounds great. Thanks a lot. If you're enjoying this podcast, please leave a review or follow us on your favorite podcast platform. It's a great way to support our program and spread the word to others. Thanks so much for listening. See you in the next episode.