What happens when conservative care fails? What if you have prescribed patient education and the ‘best’ occlusal appliance and none of it is working? That’s where surgery MAY be indicated for certain diagnoses. Listen or Watch my podcast with Professor Andrew Sidebottom Maxillofacial surgeon (who is limited to the management of TMJDs) to help us make timely and appropriate referrals to provide the best possible outcome for our patients.
Ready to learn the management of Bruxism and TMD online? Click here to enrol to SplintCourse
Protrusive Dental Pearl: Head over to the Protrusive Dental Community Facebook group where I posted an 8-minute walk-through video on how to screen which patients are at risk for getting a bite change or AOB after an occlusal appliance and how you can minimize that risk.
The highlights of this episode:
- 12:47 Why you need to provide Conservative Care first
- 15:57 TMD is a Spectrum
- 19:21 Early Surgical Intervention?
- 21:42 Acute disc displacement without reduction
- 26:40 Imaging used when managing TMD patients
- 35:10 Pain Management
- 41:03 Arthroscopic procedure for TMD
- 50:29 How much does TMJ Surgery cost in the UK?
- 53:22 Successful management of temporomandibular disorders
Check out these studies as mentioned on the podcast.
Also check out Prof. Andrew Sidebottom’s website for more information and download leaflets.
If you enjoyed this episode, check out Stay away from TMD! [SPLINTEMBER]
Click below for full episode transcript:Opening Snippet: So I think understanding TMD is about understanding that it's a spectrum of care from joint related right down to muscular related, and patients are somewhere in the middle of that. Probably about 90% of the patients I see down at that muscular end as you say.
What happens to our TMD patients when conservative care fails? Like you’ve done your patient education, you’ve given him the best occlusal appliance, you’ve worked alongside your TMJ physiotherapist, you’ve been through exercises, and you’ve even counseled them about the importance of recognizing awake bruxism, a huge player, and all this stuff isn’t working. What happens next? Well, depending on your diagnosis, the next step for some patients will be see a maxillofacial surgeon, but not any old maxillofacial surgeon, you ideally want to send someone who’s got an interest in TMJ and TMD. So I’ve got today a private physician, private maxillofacial surgeon in the UK, who exclusively treats TMD. So what this guy doesn’t know about surgery and TMJ. And what happens in the latter parts once conservative care fails, how the referrals manage, when should we refer these patients, which patients are suitable for referral to Maxfax, once conservative care fails. Let me give you a clue, if your primary diagnosis is muscular, then really, you know, really need to go and exhaust conservative care and the physio and by the way, most TMDS are of a muscular nature that myalgia and myofascial pain and there’s no real scope for surgery when it comes to muscles that are upset. That’s when we really to give the best conservative care we can and involve a pain specialist sometimes potentially Botox and lots more which we will discuss.
Now if you want to learn more about occlusal appliances, bruxism as a GDP as a restorative dentists who wants to just not be afraid of doing a TMJ exam when the patient comes into an emergency slot and they’re complaining of pain from their jaw, or they got like a facial pain and you take a step back and think Whoa, I have no idea what I’m doing here. Then I’ve set up a course just for you. You guys know that my flagship course is splint course so it’s www.splintcourse.com I’ve just relaunched it, got hundreds of very happy delegates all over the world. And we’re continually, it’s like a school family, little community on Facebook. We have these monthly meetups on Zoom, but the entire course is online on demand. Dentists from Singapore, Estonia, Ghana recently as well, India all over the world, UK, loads from the UK and US have joined the course and now are implementing knowledge that they can help their patients with bruxism management and TMD and relaxing the muscles and just doing a good examination of the joints and muscles. I initially set this course up because I was so confused many years ago about which splint do you give when? How do you give a really good Michigan splint? How to actually adjust a soft splint? So it’s got some sort of occlusion, right? And a lot of times soft splints we’ve been guilty of just you know, grab and go and just give it to the patient and let them leave and claim your 12 days or, or whatever it might be. But actually, there’s a little trick that you can do to get some occlusion on your splint. Now I cover all of this in a lot of depth with clinical lectures and visual animations, PDF downloads, you name it, I really, really made something I’m super proud of. And that’s going to help you save time, be less stressed, and actually be able to charge appropriately for your appliances with confidence. But don’t take my word for it. Have a listen to Aoife Egen, one of my lovely Splinycourse delegates. I admire Aoife so much because she demonstrates that it’s all about implementation. Knowledge is nothing about implementation. So I congratulate Aoife for applying the knowledge from splint course. Have a listen to her experiences[Aoife]
My experience with undergraduate and postgraduate was very similar and in both cases, and I felt it was lacking. So when I started Jaz’s splint course and I was going through all the modules, I just found it such a welcome shift in thinking. And I was really, really delighted to have come across it because I felt that it was the first time I was finally going to be able to really apply and yet kind of actually use all of the information was very logical compared to the theory based approach that I had experienced before that. So I started this course in December I think and so I kind of went got through all of the information by about I think the end of January. And then as it happened, I was going coming back from maternity leave at that stage. So in the last six weeks or so, I’ve applied so much of the principles from Jaz’s course already, and it’s just been great, you know, just immediately, my diagnosis has been better. Even something as simple as, you know, before, I had always just written like, you know, as part of my notes, extra oral examination, TMJ, and then a note about it. But now I actually understand what it means to if there’s a click or, you know, I just have found my notes are more detailed. And I’m not just kind of noting it, and then doing nothing about it. But I’m actually kind of acting on my diagnosis a little bit more. Sorry. All right. I just hope Jaz hears this now [Jaz]
Ladies, I heard you loud and clear. I love to hear that. That’s fantastic. Thank you so much Aoife. Now, the biggest excuse I hear from colleagues, they message me in terms of time, Jaz, I’d love to do your course. But I don’t have the time, I can’t find time in my busy life, to sit in front of a laptop. And watch these videos as fascinating and engaging as you make it Jaz. I don’t have the time. But you made the time to listen to this podcast. And I realized this afterwards, when some of my delegates were not making as much progress I want you to do well, I want you to make progress. So then I decided to put the make the course as a podcast as well, because then a lot of people can while they’re commuting, make time for education. And therefore now a new feature of the course is that you can download the mp3 of the modules. And listen while you drive, or on the train or chopping onions or whatever. And you gain most of the knowledge like that you reference it with some of the videos you have the course ebook, and all the PDF forms and gives you a new way of learning through the medium of podcast. So that’s right up your street, head on over to splintcourse.com and enroll today.
Before we joined Professor Andrew Sidebottom, the maxillofacial surgeon, we talking to you today, I’ve got your Protrusive Dental Pearl And this is a video I posted on the Protrusive Dental Community. So if you’re not part of the Protrusive Dental Community on Facebook, search it up, join. It’s a lovely little community, very helpful. I’m proud of it I one of my colleagues, Maria posted a case whereby she gave full coverage appliance, upper and lower, full coverage like a retainer and a full coverage appliance to a patient and she developed anterior open bite. And so this happens right? So it’s not just a small appliances and over eruption and that kind of stuff. And I’ve talked about it before, but a patient now has an AOB. So inspired by that problem, I saw an opportunity to make an educational videos, eight minute video made to ship to walk you through with a patient life patient there exactly how to screen which patients are at risk for getting a bite change or AOB after an occlusal appliance and how you can minimize that risk. So it’s a free eight minute video you can watch, I pinned it to the top as a featured content on the Protrusive Dental Community. So you could check that out as your Protrusive Dental Pearl. Otherwise, I hope you enjoyed this podcast. I’ll catch you in the outro.
[Jaz] Professor Andrew Sidebottom. Welcome to the Protrusive Dental Podcast. How are you?
I’m good. Thanks, Jaz. How are you? [Jaz]
I’m great. I just came back from Porto on holiday we took 16 dentists to learn vertical preparations with George Andre Cardoso in Portugal, which was amazing. And we’re feeling a little bit tired. I’ve got a few ulcers. I’ve lost my voice a little bit, typical. But hey, I’m good. I heard about your weekend before hit recording, very family orientated which was nice. Like how do maxfacts people? How do you get time to have a life? Serious question like you guys must be so so busy. Well, how do you manage it? [Andrew]
So I mean, I think I stepped down from my NHS work 18 months ago and just do private work now which has given me an extra day a week. But yeah, it was chaos before and doing a one in four on call was was hard work. But yeah, I’m enjoying life a bit more now. [Jaz]
I’m so glad to hear that and please give us a flavor and I want to know as well. With going private MFS like you do you have your own niche within MFS and what are the types of surgeries that you have niched into? [Andrew]
Okay, so, as an NHS consultant for 20 years, I developed a practice in TMD and facial deformity. I became one of the go-to people for TMJ problems from other IMFs around the UK and Europe. And the the facial deformity side of it fits in nicely. In addition, all of us kind of Do wisdom teeth and dentoalveolar work as well and I still love doing the basic dentoalveolar surgery. I just like getting my hands wet. So that’s great doing that. And so my private work, probably about 60% Is TMD-based. And then 40% is general Maxfacts and facial cosmetic surgery. [Jaz]
I’m so excited to have the chat now. They told me the background terms of how much work could you do with TMDS right on my street I am sure I’m gonna learn so much from you and we are all asked you got a platform of GDP is it all over the world who tend to listen to Protrusive Dental Podcast because they’re a little bit geeky. They want to a bit more, they like the nitty gritty details. And they have an interest in some way in occlusion or TMD. Or that’s why they started listen to this, that’s why they clicked on this episode. So let’s scratch that itch for so many listening. So first, just tell us where you work. Tell us where you work. And how did you get into that niche of TMD. Because most dentists I speak to want to stay as far away from it as possible. [Andrew]
And I think that’s true of most maxfax surgeons as well. We, what did I? How did I get into it? I kind of got into it almost not quite by default. But I at dental school, I went to a very interesting lecture by a chap called Richard Juniper, who at the time was a consultant in Oxford, and specializes in TMJ. And I was really intrigued by his kind of anatomical understanding of how the joint works and their relationship with the lateral pterygoid to the disc and the head of the condyle. And then went off to do my SHO jobs ended up in Birmingham with a chap called Bernie Speculand, who was one of the first guys in the UK doing TMJ replacement and TMJ surgeries. Liverpool as a senior SHO, none of the consultants was interested in TMD. So I got dumped with all of that work by the seniors, and thought I ought to start learning about it, went back to med school, married an orthopedic surgeon. And by default, therefore, you’ve got to know a little bit about joints. And went through did my higher surgical training in Liverpool with a guy called John Cooper who again was interested in TMD and came to Nottingham and just that was part of one of my areas of interest, along with facial deformity, cranial facial surgery, and just develop the TMJ stuff along those lines and set up a specialist clinic literally in my first week in 2001. As a max fact surgeon in Nottingham, and having the time to spend with the patients at the first visit, when they get referred to secondary care is the key to management of these patients is spending time with them. [Jaz]
That is brilliant. I love your story and how one stem from another and the fact that you married orthopedic surgeon, I think gives you an edge for sure. It totally gives you an edge. I love that. The kind of themes we’re exploring today, if we were to achieve two things on this episode is one to gain insight what happens when us, dentists have really exhausted conservative care, and they come to you? And what are the types of diagnoses that lend themselves to a better prognosis? What kind of surgeries do you do? I mean, in this short time, we can only cover so much I know you’re coming to visit us on the live of Splint Course, which I’m really excited for you to meet the delegates who have taken a real interest in the conservative management TMD. So really excited to see you in May and June for that. But the first question is, what do you think? What is the level of care that you want general dentist to have carried out before that patient is referred to you? Because and please do tell me what percentage of referrals that come up come to you sort of bounce back and say actually, there’s no indication for surgery? And then do you sometimes just take over and do the job that perhaps you feel that our colleagues should have done? [Andrew]
Yeah, so one of my roles at the moment is as the East Midlands advisor for NHS England, Oral Surgery, so I’m the emcee and lead for oral surgery. And one of the things that we’ve done is send out a missive to all the dentists in the region about what they should be doing for patients in primary care for the initial management of TMD. The guys in Darby audited the referrals before and after that, and found very little change in practice. And that roundabout 80% of patients had a basic rest, anti inflammatories bite splint protocol, before they came into hospital. The Royal College of Surgeons guide suggests that patients should have a six months of conservative treatment prior to referral in. I don’t agree with that. I think that misses some of the patients that will benefit from early surgery, particularly younger patients with an acute severe restriction of opening. So I think a basic rest, anti inflammatories, reassurance that the majority of patients even that we see in secondary care, don’t go on to need surgery. And reassurance that clicking is something which about a third of the population have any way and most people with clicking don’t get problems. So don’t worry about the noises that are coming from your joint. We don’t worry about noises in our knees and hips and shoulders. So we shouldn’t worry as much about TMJ noises as some people stress and basically to just give that reassurance that you know, the biggest thing I would advise everyone not to say is never tell a patient they’ve got arthritis because as soon as you say that they assume they’re going to need a joint replacement, [Jaz]
Especially if they started googling it. [Andrew]
Absolutely, yeah. [Jaz]
Which they do. TMD patients I’ve had, which eventually watch my dental podcast, which is, can you believe it, they didn’t know, my podcasts are meant for dentists. And they search these terms, which only a dentist would ever search, right? And then they end up with me and they come, and then I’ve seen a few of them. That’s kind of like how I’ve also made a sub interest in TMD. But my mission was always to be really good with conservative care, because I can treat so many of my patients with really good conservative care. And one thing maybe we’ll touch on is giving an occlusal appliance with intent based on diagnosis. And with that comes, you know, one important consideration that yes, you know, you shouldn’t say arthritis and stuff to your patient, because they’re worried, but loads of these patients, their diagnosis is in the muscular region. And correct me if I’m wrong, but you know, they don’t, there’s gonna be no indication for surgery for somebody that’s muscular, that definitely needs rest. So just please expand on what percentage of referrals that you get are perhaps muscular, and they’re not, you know, osteoarthritic or intracapsular, that you feel as though hang on a minute, we need to just go back and break things down, go back to basics and apply conservative care. [Andrew]
Yeah. So I think understanding TMD is about understanding that it’s a spectrum of care from joint related right down to muscularated. And patients are somewhere in the middle of that, probably about 90% of the patients I see down at that muscular end, as you say. So of the patients that get referred to us in secondary care around about it. The easiest thing to think of with TMD management in secondary care, which I tell all my trainees is it’s an 80% disease. So 80% of the patients we see in secondary care, get better with conservative measures. 80% of patients who go on to have arthroscopy get better with that, of those 80%, 10% don’t need further intervention, despite not getting better with arthroscopy, because it becomes very clear that they haven’t got the joint related pathology. Of the remaining 10% that go into open surgery, 80% of those get better. And of those that don’t, when they’ve got significant pathology in the joint that go on to joint replacement, you look at that. And of those 100 patients who have come in initially to secondary care, probably one will go on to open surgery. And about point one will go on to need a joint replacement, so very few. So as a surgeon, Maxfax surgeons aren’t interested in it, because you don’t operate on the majority of your patients. [Jaz]
That’s an interesting take, cctually. If it was more surgical lead, maybe Maxfax would have more of an interest in it. But you know, we agree that there’s so much general dentists can do with good conservative care, perhaps teaming up with a local physiotherapist and following a hierarchy of things, where we’re both well acquainted with Kreena Panchal, who again, will also be there in the dates of May and June on the live version. So it will be great to actually put our heads together and see how can we help our GDPs give better conservative care, and that’s essentially what it’s about. And with that Prof, I want you to say, there’s a rule that one of my mentors taught me about PDQ. And just as you said, with the clicking, and lots of patients get concerned and worried. And you should just reassure them a clicking is normal, PDQ. So it’s only really an issue in any real diagnoses within TMD, which is an umbrella term, if it gives a patient’s pain. If PD means let’s say dysfunction, okay, so they’re not able to chew properly or quality of life. If it doesn’t satisfy any of those three, then really, there’s there’s no reason to actually intervene at all, not even with conservative care. Really, if it’s not giving any of those. When any of those three happen, then of course, conservative care. And if that fails, which 20% time it may do, but to be fair, I think if we only had a group of patients who had muscular symptoms only, and you gave them really good conservative care, and we can get into heated debate, maybe but not just give them a soft splint. Okay, well, we’ll talk about that towards the end, then I think we will go beyond 80%. And some of the literature says that, but the general lecture 70-90% patients will get better, even just without an appliance, just giving them some advice and rest, a physio, no appliance will do well, and we know that. What are the kind of cases that you think dentists should and it’s really interesting mentioned should be referring to you without conservative care first, because you feel as though okay, this patient is just going to be worse off in six months with conservative care, and they actually need early surgical intervention. Can you describe those type of cases? So the diagnoses. [Andrew]
So it’s a term that I’d be amazed if any of your listeners come across, which is called Anchored disc phenomenon. And basically what that is, is with repeated compression of the joint and one of the things that we’re increasingly aware of is that TMD is related to repeated compression, micro trauma of the joint from clenching or grinding, usually clenching rather than grinding. And to put it in a simple term, they squeeze out the fluid of the joint. So if you wash out the engine oil, the engine ceases. And what happens with the joint is that you lose the glide component. So your initial rotation of about two, two and a half centimeters in the lower joint space continues, the upper joint space loses its viscosity, it loses its lubrication and sticks. And so the disc is stuck against the fossa, you don’t get the glide. So they stick it round about 25 millimeters. And anyone with that onset suddenly, so they getting on fine, suddenly they come in, I can only on my mouth two fingers or less, needs urgent referral, because those are the ones that do extremely well with an early washout and early arthrocentesis. And do extremely badly if you delay and delay and delay. So those patients who are delayed beyond one year, their outcomes are about 50% success. Whereas those that are treated, within three months, you’re looking at about 95% success. [Jaz]
Wow. And we and these patients are different from that patient in their 40s or 50s, who’s always had clicking, clicking, clicking, and then sometimes they get the the lock, which they can fix. And then eventually they get down to two fingers. And we suspect a disc displacement without reduction. So the disc is not able to come back on the condyle, the condyle cannot translate as well. And that’s a different beast to the kind where they get like you described more sudden. And that makes sense. Now, when it comes to patients who have intracapsular disorders, and they have that disc displacement, locked or the closed lock, and the jaw deviates towards, or deflects to one side even and they cannot open, they’re in pain, acute pain. Why do you see the success in conservative care in there, because this is where I give reduced prognosis to my patients, I can still help a lot of patients. And actually funnily enough soft splint, the bite raising can help those patients to recapture and then various things. But the longer that’s happened, the worst prognosis? Is any evidence that early surgical intervention in those kinds of cases can help or what would you advise general dentists to do in those acute disc displacements without reduction? [Pav]
Yeah, so I think a lot of this is dependent on understanding the basic kind of pathophysiology of what’s going on. So what you’ve got with this displacement is that you’ve got compression of the joint. And if you compress the joint often enough, it starts getting thin, and the retrodiscal tissue stretch, and then the disc slips forward. So when you open, you go past the back end of the disc, and then you get the click as it relocates in position, the click can also occur, because the retrodiscal tissues thicken, in adaptation to the increased load. And that can also click over those. So those are the ones that you can get click click, sometimes. The reason you get a lock isn’t that the kind of old fashioned thought processes of the disc is just stuck there in front of the joint, what actually is probably happening is that you’re getting to a certain point on the retrodiscal tissues, the tissues are so inflamed and uncomfortable that the muscles Stop it, and they go into spasm and they stop you moving forward. So that’s either spasm of the lateral pterygoid, on the front end of the disc, or spasm of the opening muscles, the masseter temporalis, which literally, because it’s painful, it stops you’re moving, it’s like a limp. You don’t on purpose limp when you’ve sprained your ankle. And it’s the same with your TMJ, your body knows that it’s going to be painful, and it suddenly says, I’m not going to move there. And then your jaw deviates over towards the side where the pathology is. And you get that restricted opening. So trying to release the muscle spasm, trying to offload the joint with your splint is going to help that patient in the initial phases, and probably will get significant number of those patients improved with good splint therapy, good rest and avoidance of that whilst you’re waiting for a referral onwards. But yeah, don’t hesitate to get the splint in there and kind of offload the joint really. [Jaz]
Do you think that kind of patients should be also going down the conservative care for six months before referring to someone like you perhaps or is that warrant a referral to you to start also being involved in that patient’s care? [Pav]
So I think the problem you’ve got in Maxfax is that there’s only about a dozen of me around the country. And there are about 300 Odd maxillofacial surgeons who aren’t comfortable providing early arthroscopy, arthrocentesis and therefore, what will happen is that they’ll get referred in. The patient will be seen by often a junior member of staff who will say, Oh, yeah, these need conservative treatment, or they’ve been having conservative treatment, or let’s give it a bit longer, and they get delayed in the system. So it’s about knowing who to work with as much as how to get that process going. And, you know, I’m not being demeaning to my colleagues, some of them are brilliant cancer surgeons and what have you, and I wouldn’t want to touch that side of things. But similarly, it’s an awareness that you’ve got your own limitations of what you’re comfortable with, then it’s probably worth referring into somebody who does have, most regions will have one or two surgeons who have an interest in TMD management. And it’s really about finding out who that is in your area, and working with them to kind of get those patients referred into their clinic. At the moment in the NHS, it’s a disaster regardless, because I don’t know what it’s like for you guys down there. But at the moment, for a routine referral in East Midlands, it’s like 40 weeks Wait, and TMD will be a routine referral. So you know, you’ll have a 40 week wait, and by that stage, they’ve missed the boat. [Jaz]
Agreed. And this yeah, like I said, similar here, and just on the idea of getting finding someone who’s local to who can assist you, as a general dentist, with those complex intracapsular locked as acute, but I think we still need to apply conservative care that might be just a little bit different. And we’ll talk about that when we come to the live courses, obviously. And that may help patients a lot while they wait, especially if you get that lateral pterygoid to calm down, because I like to lateral pterygoid to calm down and a lot of those cases will get better. And just like you said, the beginning, it’s everything that’s a spectrum, there’s no purely intracapsular, probably less purely intracapsular, there’s always a degree of muscular involvement as well. And one of my favorite analogies for the relationship between the condyle and disc is that the disc is like a bar of soap. And with the compression that bar of soap can slip. And obviously that’s a very simplified way of thinking about it. There’s lots more anatomical changes that can happen. But essentially, yes, when someone gets restricted opening and your suspect a disc displacement without reduction, my Inkling is to help out. But I’m also thinking about imaging. So let’s talk a little bit about imaging of those patients who either conservative care has failed, good conservative care has failed. Or they have disc displacement without reduction before even surgery, what kind of imaging Are you providing for these patients? [Andrew]
So I’m probably a little controversial in my views on imaging. I very rarely will get an MRI. The reason being that the MRI scanners we have in this country, first of all, the majority of 1.5 Tesla. And so the views aren’t that great. The radiologists are few and far between who are good at interpreting them. And when you look at the best series in the world, from the likes of the ninth People’s Hospital, Jiuyuan unit in China, even there, the accuracy of diagnosing a disc tear is about 50%. And so if you base your surgical intervention on your MRI 50% of the time, you’re going to be wrong. An audit that we’ve done and not seen as similarly done a similar audit in Oxford, and colleagues in America have audited their practice. When you do an arthroscopy and you find a disc tear, a lot of colleagues would say, Oh, you need to take the disc out. My feeling is based on an audit of 115 patients that we’ve presented, but haven’t published yet. 50% of them get better with a disc tear. And that’s its own disc tear, which can’t heal itself because it’s avascular. So if you then said, Okay, well, I’m gonna base a surgical discectomy on an MRI scan 50% of the time, it’s got the diagnosis wrong, and 50% of the time, you’d have got better with just an arthroscopy. So, you know, 75% of your patients, you’ve taken the disc out unnecessarily. And that sort of data correlates with a couple of studies in the literature from Sweden, a chap called Anders Holmlund did a lot of work on diskectomy and found that following arthroscopy, if you did a diskectomy, about 50% of patients got better. Whereas if you didn’t do a diskectomy, if you didn’t do arthroscopy, 80% 85% of patients get better with a discectomy, so that means 35% of patients probably would have got better with arthroscopy alone, so it kind of correlates with all that. So that’s why I’m not a huge believer in MRI. MRI, in theory, if you take a good history, and do a good clinical examination, the MRI will only confirm what you clinically know. [Jaz]
I’m glad we’re in the same viewpoint actually because I find as a GDP who’s got an interest in this difficult for my patients to accept having an MRI and going to London to have it. There’s a few people I know who do it but they’re few and far between. And a lot of time with my history and knowledge of anatomy, you can get, you can suss out the diagnosis. So I agree with you on that. I’m sure there’ll be times where something’s just not quite right. And you will need to take some form of imaging. I recently had one of my delegates on Splint course in our Facebook group, he posted a case where acute pain on the right, limited opening with a deflection so we’re discussing, okay, we suspect disc displacement without reduction on the right side, but it’s quite sudden onset. Can we explore? So he referred on and they did take an image now I’ll have to check out I’ll put this in the show notes. Exactly what type of imaging it was because I don’t want to get it wrong. We know that MRIs are good for looking at the disc and soft tissues, we know that CBCT’s are better for for hard tissues, but they did diagnose a right side condylar fracture, which was fascinating. And they were they were surprised in the report that they wrote. So yeah, those kinds of things yet, when the when something’s really unusual, then I’m sure you guys are would do that. But for many cases, it may not change your management, is it is that fair to say that with your differential diagnosis about imaging, it may not change your management with the presence of an MRI? [Andrew]
I think the other thing that you need to understand about an MRI, have you ever, if you’ve ever had an MRI, you will understand [Jaz]
For my shoulder? I have Yes. [Andrew]
So it takes about 30 minutes. How do you lie still for 30 minutes, with your jaw, it’s and then you’re trying to open a jaw into a bite block, which is an unnatural movement, you’re not going to move past a point that might be painful. So if you had a painful click, you’re going to stop before you get the pain because you’re not going to hold your mouth for three minutes with that pain in that painful position. So you will often get an over diagnosis of limited disc reduction from the MRI, not because the radiologist has got it wrong, but because of the unnatural surroundings that you have with an MRI, you know, and everyone that says oh, well, you get a dynamic MRI. A dynamic MRI doesn’t show a joint moving like that. It shows a joint in that position for three minutes, then that position, it’s then that position for three minutes. And then they combine it to make it look as though he’s moving. And even with that, it’s not natural. So you’ve got to take your clinical diagnosis, your clinical diagnostic skills, to the level that you’re thinking, Okay, what’s going on inside that joint and you’ve got it in your brain, what movements are happening, and then you can use your MRI to confirm that. So one classic, I remember I got asked to go over and treat a Saudi in Saudi Arabia. And this girl was the daughter of the hospital owner, multibillionaire and the MRI showed an anchored disc. The MRI showed a disc displacement without reduction. And they said, Oh, I think she needs a discectomy and they had various people say that I said, Okay, well, no, we’re going to do an arthroscopy. So I did an arthroscopy on table mouth opening went from 20 to 44 millimeters post op, three months mouth opening 45 millimeters pain free, disc relocated on the MRI. That’s an anchored disc phenomenon. But what the scanner show is that the disc was stuck in front of the joint. So you’ve got to listen to what the patient’s saying. Listen to your experience and work through that and think, Okay, what could be causing this and the anchored disc phenomenon is it tends to be under 30s. I’ve always been aware of these younger patients with acute severe restriction. Yeah, the majority of kind of teenagers, it’s myofascial pain, been caught out a few times with new diagnosis of rheumatoid arthritis or inflammatory arthritis. A few others that you get this acute severe anchored disc phenomenon, but a lot of patients under 30 is muscular. But those acute severe restrictions is going to be an anchored disc before it’s going to be a disc displacement without reduction. [Jaz]
Well, that’s a really great insight. And just to add to an MRI study that was done, they and I’ll put the exact reference in the show notes, you’re probably familiar with this study where they had symptomatic patients, and they took an MRI, but they had asymptomatic patient patients, and it took an MRI of the joints. And they found that a quarter of maybe even a third a quarter to a third of these asymptomatic group have a disc displacement with reduction and had a pathology. And then about a third of the patients with symptoms had no pathology on the MRI. And what it also goes to show is that we very much need to respect the biopsychosocial model of disease and just because those patients had a MRI diagnosis of disc displacement with reduction, they had some sort of pathology per se. It didn’t correlate to pain and What physical abnormalities or pathophysiology or problems, they don’t always manifest as pain because pain is very complex beast. Do you work with other specialists when it comes to pain management? Because I imagine that’s a big part of what you do. Please tell us more about your reflections on the relationship between an actual disc injury or positive finding or lack of and pain. [Andrew]
Yeah. So I think the first link you were saying about working with a physiotherapist, the more treatments I’ve carried out, the more I’ve worked with physiotherapists. So I’ve got now about six or seven physios that I work with around the country. All of them are pretty much specialists, TMJ physios, you can access them through the acptmd.com website. And Kreena who is on the course is one of those and I work very closely with Kreena, I’ve got three around Nottingham that I work with and one now in Lincolnshire, a couple in Sheffield, and one other in London. So these guys are fantastic. And they’re also good at emailing you back and saying, Andrew, I’ve done what I can, please can you put a bit of Botox into this muscle, because I think that’s something which is very good at breaking the cycle. The other thing with Botox is that it’s very badly taught to dentists by and large. So it’s injected suit, too superficially. It’s injected in the wrong places, it risks damage to the zygomaticus muscle, which runs from the front of zygoma, to the corner of the mouth, because one of the areas of major muscle spasm is the upper anterior masseter, just here. And if you try to inject that, it will leak into the zygomaticus, which is just next to it. And you’ll end up with a patient that can’t smile for four months. And so they won’t thank you for that. So when you’re injecting with Botox, you’ve got to find where your muscle spasm is. And what say to all of my juniors is muscle spasm. Teaching patients where muscle spasms, you get them to feel the muscle firmly. And if they can feel a speed bump, they go over the muscle spasm and it’s uncomfortable. And that is one of the keys to where the physio works is massaging that area of speed bump and running your finger over that speed bump for a minute, four times a day. It stretches the muscle. It helps improve the blood supply and it releases endorphins so that they get pain relief. Similarly, you look at muscle relaxant medications low dose, tricyclic meds, which a number of my colleagues are very quick to jump patients onto those meds. I think you’ve got to look at less invasive ways of doing it first, you know that they are quite difficult drugs to manage. And if you’re not used to using them, then really they should be managed by either the GP who are quite used to using them for a lot of things now, or a pain specialist. And I will try either low dose amitriptyline, nortriptyline or gabapentin, pregabalin. And if those aren’t working at that stage, I send them to my pain management team. And I have about three pain management consultants that I work with, that are very used to what I do. And similarly, they bounce patients back and say, Andy, could you put some Botox in this patient? I think that will help. In addition to what we’re doing in the medical management side of things, I think it’s very easy to just FOB patients off with muscle relaxant meds, when actually, it they need a more holistic approach to management. [Jaz]
And with your pain management team, as well as cognitive behavioral therapy, what other modes of sort of intervention are available from the pain management side. [Andrew]
So I think you’ve got to consider with these patients, I, in a lot of my lectures, I draw three circles interlinked. And there’s this internal derangement, there’s osteoarthritis, and there’s myofascial pain, and then there’s a double arrow feeding into all of that same psychology. Because if a patient has anxiety or depression, they’re more likely to clench and they’re more likely to feel pain. If a patient has pain, they’re more likely to become anxious, depressed, and clench their teeth. So it’s a two way cycle that you’ve got to look at. So you, there’s the occasional patients, I treat two consultant psychiatrists. It’s always interesting having that feedback with them about you know, you do realize that you need to see psychological management techniques and saying, Yeah, we do these things and blah, blah, blah. But yes, you’ve got to interact with psychologists with CBT therapists with psychiatrists on occasion and Kathy Fan from Kings produce a very nice paper where they have developed a tool, which works out all the patients that come into their TMD clinic get put onto this tool, and it says, This patient is high risk of anxiety, high risk of depression. And then they link in with their psychiatric team to manage that side of the problem as well. And then on top of all that, you’ve got the medical problems. So you’ve got the fibromyalgias, the inflammatory arthritis, which you’re linking in with the rheumatologists. So, it over the 20 years of working, I’ve worked with more and more colleagues and more and more colleagues work with me and it was beautiful working relationship in the end. I’m sorry, I left [Jaz]
And that’s what it’s all about, you know, multidisciplinary care. So the definitely was all about and I’ll put reference again to the OPPERA study, which talks about all those other comorbidities. And I’ll put that in the link as well, because we discussed that with an episode with Kreena a long while ago. So we’ve talked a little bit about the kinds of cases that should be seen little bit sooner, the importance of conservative care, and you gave us some success rates. I love the 80-80-80 sort of rule if you have, Pareto principle comes to mind. When you talk about arthroscopy, please describe to general dentists, What is an arthroscopic procedure for with regards to TMD. What are you actually doing? And what is the sort of prognostic features or what are the features that will suggest okay, this patient has a good prognosis or a bad prognosis from an arthroscopy? [Andrew]
Okay, so, arthroscopy is usually carried out under general anaesthetic. Patients don’t need antibiotic prophylaxis, orthopedic surgeons have not been using antibiotics for years and years and years for knee arthroscopy. The scopes we use, by and large, a 1.9 millimeter diameter and 30 degree angled, the scope I use now is a disposable 1.2 millimeter. And on viewing scope called an on point. It’s smaller, it’s easier to get into the joint, it theoretically causes less damage. But the risk is that sometimes you don’t quite get into the anterior recess, the majority of pathology, you see, an arthroscopy is in the posterior portion, or the mid zone of the disc. Arthroscopy realistically, unless you’ve got a disc test, you’re only going to see the upper joint space. So you will miss low joint space pathology. But you basically descend the joint, you then put in the telescope, and then you look around the joint, and you try and work out what’s going on, the commonest thing you’ll see is that this folding of the retrodiscal tissues because they’re stretched. And so when you open the mouth, you’ll see this kind of little wave formation flatten out as you move the scope through the joint. And then the next thing you’re going to see is, is there any inflammation on that tissue? Does it creep up onto the avascular disc, which is called creeping synovitis? And is there a hole in the disc, and you’ll see that a chronic tear has a nice rounded edge. And acute tear is a bit more jagged. And probably an acute tear is more likely to heal, and the patient get better than a chronic tear. Because what happens with a chronic terror is you get adaptation. You know what we’re doing as surgeons is facilitating the patient to get better. So if you like we’re helping God to get the better. We’re not God. You know, I know they say, you know, what’s the difference between God and the surgeon. God doesn’t think he’s a surgeon. But basically, what we’re doing or what we should be doing as surgeons is helping the patient’s body to heal itself. And so what you get from an arthroscopy then, and level one arthroscopy is literally putting the scope through the joint, looking around the joint and flushing it out, under pressure. You need to do it under pressure, because it distended the joint, you need to flush out enough fluid. So you need 200 mils plus a fluid to get rid of the inflammatory mediators or those free radicals. And what that 200 mils starts doing is getting rid of the free radicals in the lower joint space as well by diffusion through the retrodiscal tissues. That’s work that direct net San has looked at from Israel, that shows that less than 200mils. 200 mils is that kind of key 99.9% of all free radicals have got rid of. 100 mils, you’re looking at about 97%. 50 mils is around about 50-60%. So you really need to be flushing through a lot of fluid. The pressure distends the joint and breaks down adhesions in the joint that are forming. And it also what happens what you see with an anchored disc is like little fibrillation is where the joint surfaces have been stuck together and then pulled apart. And the way you can imagine that is if you put two surfaces of glass together with a thin layer of fluid and then you pull it apart. You can see those little strands forming. So that’s what you would see with an anchored disc phenomenon. Level two arthroscopy and there’s realistically only one person in the UK that It does this frequently, is putting a separate scope in and taking biopsies and freeing up tissues. Level three is putting three bits in and hiking the disc back. Now state that there is no good evidence that level two and level three given added advantage of a level one is categorically in the literature, there is no evidence that added procedures arthroscopically give any advantage. There is likewise no evidence that open disc plication, putting the disc back into position gives a long term relief of symptoms over and above dealing with any other pathology in the joint. So disc plication in the 70s and 80s was a common procedure. What happened was that five, six years later, the patient got clicking again, you did another disc plication, five, six years later, it comes back again, by that stage, the fact that you’ve opened a joint two or three times, you’ve got a degenerate joint. And so disc plication went out largely as a procedure through the 90s. There’s still people who will do it regularly. And state they get good outcomes from it. My own view is that I do it probably about 5% of my cases, I’ll do a dislocation. This is with open surgery. Of those, only about 50% of them get better. Whereas everything else I do, which is deal with, if there’s damage to the eminence, if there’s damage to the disc, if there’s damage to the condyle, I’ll deal with all of those at the same time. My success rate with doing that is 80%, bizarrely, as opposed to if you just do an emenectomy, your success rates about 60% If you just do a discectomy, your success rates about 60%. So if you address all the pathology in the joint with open surgery, then you’ll get a better success rate. But if you do disc plication, you probably won’t. And it possibly is because you’ve got the diagnosis wrong. [Jaz]
I mean, that’s I’m sure there must be like there is dentists, difference in opinions amongst all surgeons. And this is where we need more evidence in our profession to know about these, you know, long term success rates, but very good insight now when it comes to arthroscopy, as you mentioned, and then you place fluid inside to distend the joint is that then classified as an arthrocentesis. So IE arthroscopy is the exploration. Is that an arthrocentesis? Fair term to say that that’s the flushing of the joint? [Andrew]
Yeah, so arthrocentesis, by definition is putting two needles into a joint. And that can be one needle with two lumens. But two needles into a joint, and flushing the joint fluid through under pressure with a volume of fluid. Arthroscopy is exactly the same type of that, but one of those needles is an arthroscope. [Jaz]
Got it. And those patients who have a acute disc displacement without reduction, who maybe is in their 40s or 50s. And conservative care is not working, they’ve come to you. Is arthrocentesis or arthroscopy the next step for those patients largely and then if so, is it again, an 80% success rate? So unlock them. [Andrew]
Yeah. So when I’ve looked at my outcomes, you know, I’ve got now a series of roundabout 2500 patients where I’ve got the prospective data of an even when you look at that group, and you classify them according to Wilke stage and Wilkes is still, it’s the only classification system we have. But it’s controversial. There doesn’t seem to be a very clear correlation statistically, that a patient with a Wilkes V, which is a severely damaged joint or deranged joint does significantly better or worse than a patient with a Wilkes II. The trend is that Wilkes II does better than Wilkes V, but Wilkes V is like a disc tear. And so 50% of my patients with a disc tear get better. Whereas if they don’t have a disc tear, and this is again, a study, which we’ve looked at 596 arthroscopys, their risk of or the success, if you’ve got disc pathology, means that about nine I think it was 9% went on to needing open surgery. Whereas if there was no disc pathology is about 2% [Jaz]
That I’m gonna have to boil that down again, and look at all these percentages because they’re very fascinate because essentially, it’s about helping our patients. I think the first port call is to get them there, right help with you, or someone who’s experienced with that. And then these Micro sort of diagnoses that are made with surgical interventions, it’s about getting the right treatment because I’m sure you know, like you said, every surgery is unique that you do and Every patient is unique and you will not just do one thing you’ll address all the things in there. That’s what I was thinking in my head. Okay, these percentages as a general dentists, I mean, if you don’t mind me asking and this can be off the record if you want me to, as and when we send patients to colleagues like yourselves who are very experienced in this and this is exactly what we want we you know, I think we want to send, I mean in my group of hundreds of delegates, right, we are desperate for people who can help with this at the next level when conservative care has failed because because my group of dentists are really good at conservative care. So I’m actually really glad to have found you as someone to recommend who has experienced in this what are the kinds of things that we say to our patients terms of budgeting and fees because you know, this is something that you know, with NHS is massive waiting lists and whatnot and you don’t know you’re gonna get I’d love for them to be seen by us, more complex cases who conservative cares failed, what kind of because I want to set my patient up. I don’t want them to come to you and say I can’t afford this. How’s it work with insurance as you charge and and what other kind of fee structures? [Andrew]
So most of the private health care insurance companies cover all of the stuff to do with TMD. So a lot of my patients Bupa or AXA. AXA are a problem for me because I’m not fee assured with them but Bupa, Aviva WPA, vitality, etc. All of their fees are covered. Some companies you’ll have an excess to pay, some companies don’t cover the surgeons fees. So for me AXA cut the fees that they pay by 40%, five years ago. And I didn’t want to accept that fee cut, but that’s my choice. Other surgeons will accept their fee rates so. But if you’re privately insured, it is covered by and large, and the surgeon should tell you, if you’re likely to have an excess to pay. You can find out who they’re insured by on the PHIN site, which is a government site which all surgeons have to submit their data on to and it says what they’re doing and what they have. The problem with the PHIN is that there isn’t a strict code for TMJ arthroscopy until recently. So on that site, I do a lot of ankle arthroscopy and a lot, a lot of knee arthroscopy, because it’s been coded as that. That’s changing. And, you know, hopefully it will become more apparent, but self pay, again, it varies between regions, so you will pay a lot more London prices, in Nottingham, for a unilateral TMJ arthroscopy, it’s around 3000 pounds, bilateral about four and a half. And it’s usually a day case procedure. So you come in, [Jaz]
That includes the anesthetist fees? [Andrew]
Everything in. Every cents. [Jaz]
That’s retty good. That’s what I think that’s pretty good. I’m sure the figures are much meatier in Australia in the States. [Andrew]
Yeah. They are. [Jaz]
Okay, that’s a really good insight to have, you know, because sometimes patient unsought, to give them a ballpark figure that’s really useful. Prof. Thanks so much for that. And [Andrew]
Consultation fees will be on the PHIN site as well, of course. You know, Mr. Sidebottom charges 200 pounds for his consultation, or Mr. Evans charges, 250 pounds for his consultation and whatever. [Jaz]
Got it, got it. And then that’s really useful information for us, general dentists listening to this. Last thing to ask you generally is, obviously I’m really looking forward to meeting you in the flesh in May and June to do the live lectures and you get to meet the delegates who are passionate about treating the TMD patients in general practice with good conservative care. And maybe even you’re slowly inching with more complex intracapsular cases as they develop the practice which would be a great help to you I’m sure you’re desperate for dentists who are good at providing conservative care. So I look forward to meeting you live and geeking out all about that. And you get to see what we teach the dentist as well. What is the main message you want to send out to general dentists or general dentists when it comes to the successful management of temporomandibular disorders? [Andrew]
Okay. Without swearing don’t believe a lot of the BS that there isn’t the internet. Simple management measures are largely beneficial for the majority of patients. So on my website, andrewsidebottom.co.uk, there’s a free to download information leaflet which I recommend all my patients download, which covers pretty much what I tell them in the initial appointment, which is, you know, first of all, it’s not likely to progress the surgery is not likely to develop to arthritis. The majority of patients can get better with simple conservative measures. This is what how, what’s happening, this is what causes a click. The only things realistically we should be treating in secondary care are patients with persistent pain restriction, or locking and locking is kind of gets stuck as you open or you get stuck as you close. And that is happening relatively frequently. So I wouldn’t tackle anyone with just a clicky joint, I don’t want to know, they should just be told, yeah, you’ve got to clicky joint, that’s fine. So 30% of the population, the vast majority of people don’t develop problems with that. But you are slightly more prone to develop problems because of it. But just because you’ve got it doesn’t mean that you’re going to have problems. [Jaz]
Yeah. Are you more in demand after the pandemic, in the sense that do you think there is because of the stress and the change and the lifestyle changes and the work from home and you name it? Do you feel as though in your practice these are resurfacing now? [Andrew]
Yeah, I think everyone has seen an increase in TMD type issues. Because as you say, of the clenching and what have used the stresses of it all. Obviously, my viewpoint is somewhat skewed, because I’m dealing next door to a trust, which has a 40 week wait. So before the pandemic, 10% of my patients were self pay. Now, about 50-60% of my patients are self pay, because they don’t want to wait for two weeks to get a diagnosis. The other interesting thing, which is just an anecdotal aside, I’ve seen more facial cosmetic surgery in the last year than I have done in the last eight years. [Jaz]
Is that you mean like facial cosmetic surgery gone wrong. [Andrew]
Zoom faces. No. Looking at their face on Zoom and thinking, Oh, my chin looks a bit fat, my chin looks flat, what my wrinkles [Jaz]
Indeed the zoom, boom. Thank you so much, Prof, for giving up your time to come on the podcast. I really appreciate I think we covered a lot of ground today. But like I said, I look forward to meeting you. And going a little bit further for those dentists who are already a little bit inclined towards this. This will also help them but we’re gonna go a little bit meatier and a little bit get again to the nitty gritty. So thank you so much for giving up your time today. [Andrew]
Not all, cheers.
There we have it, guys. A interesting perspective there about what happens if conservative care fails. What about those complex intracapsular issues. Thankfully, they’re not as common as muscular. Muscular issues are far more common, which is why the splint course can help so many of you who are looking to delve into a world of TMD, but you don’t want to go limited to TMD. That’s what I do. I’m a restorative dentist. I like to do my rehabs and stuff. I like doing Invisalign. But I’m confident when it comes to TMD consultations, and I refer the really complex ones which are intracapsular on because their success rate is lower in those cases. So I’m very good at screening about success and how it can help the majority and majorities patients just need a bit of TLC, education, physio and a splint. That’s it. Now if you’re looking for a live in person version of this, it will take like three days for it to happen. But if you want a one day introductory live course, I’ll be teaching with Kreena Panchal, our physiotherapist at the Dentinal Tubules Congress in October 2022, later this year in Heathrow. So if you don’t learn more about that go to protrusive.co.uk/congress that’s /congress. That will take you to a page more about our course how to do a TMD examination, how to palpate the muscles, how to come up with a differential diagnosis and how to work alongside your physio and which occlusal appliances to consider when, that’s what we’re covering throughout that day and the Tubules Congress if you’ve never been to it, it’s electrifying. Such a great atmosphere of dentists, the energy is just through the roof, you’ve got the best educators, you got the best parties. So wherever you’re on the world gonna come to Heathrow London in October, join the Congress. It’ll be amazing to see you and if you want to book onto my workshop, it’s seven places left only so check out protrusive.co.uk/congress. I’ll catch you in the next episode, guys. Thank you so much.