Help! My Patient Has a Small Mouth! Working Alongside TMJ Physiotherapists – GF020

Jaz’s Introduction:
Hello, Protruserati. I’m Jaz Gulati, and in this Group Function where we just focus on one theme, today’s big topic is “Help! My patient Can’t Open Their Mouth!” And you’ll be amazed with some physio with some exercises with some training if you like your patient can actually open significantly more allowing you to do better dentistry and allowing the patient to get better outcomes. We’re joined today by our first ever Israeli guest Dr. Greenbaum who is a physiotherapist who specialized in the area of TMD and he’ll be coming soon to the UK.

So I thought ahead of his visit, let’s talk about a really important topic that I think is going to help you guys in the real world where our patients are struggling to keep their mouth open. What causes this and how can we get involved either just by yourself or working in tandem with a physiotherapist? Let’s join the main episode now and I’ll catch you in the outro.

Main Episode:
Dr. Greenbaum, welcome to the Protrusive Dental Podcast. How are you?

[Tzvika]
Hey, hi Jaz. I’m very well. Thank you very much. And thank you for inviting me to speak about my favorite topic, which is Rehabilitation of Patients with Temporomandibular Disorders.

[Jaz]
It’s great to be able to help our patients in pain. And this is exactly what it’s about, pain and discomfort. And I’m going to really try and extract all the knowledge and experience that you have. But just share with the Protruserati listening right now, what is your background? How did you niche into rehabilitation of temporomandibular disorders and psychogenic and in that area?

[Tzvika]
Well, my bachelor’s degree was back in 2004 in Haifa University in Israel. And after that, I headed up to Australia, South Australia to learn a master’s degree in musculoskeletal and sports physiotherapy and a very well-known degree. But in that degree, I started to get into the topic of cervical spine.

Upper cervical spine rehabilitation of patients with headaches. It was a new thing for physiotherapists to rehabilitate patients with cervicogenic headaches. And when I came back to Israel after the Masters, I started to see many patients with headaches. And then I realized that many of them are complaining on temporomandibular disorders.

Back then I didn’t know exactly what, how to define it, but it was clicks, lockings, pains, bruxism, all kinds of complaints classically involving the masticatory system. And then I’ve realized that there is a topic that is very relevant to my patients, to a majority of my patients, that I don’t know enough.

And that was the trigger to start the PhD project in Tel Aviv University back in 2012 or 2013. And there was a professor, Professor Winocur in Tel Aviv University that was actually looking for the physiotherapist to join his team to research the involvement of cervical spine in patients with TMD and that was an excellent match because I could learn from the dentists about our facial pain specialist basically about temporomandibular disorder, and I could share my knowledge about cervical spine with them.

So that was a five years of ongoing research project where I was assessing patients with temporomandibular disorders for cervical spine involvement impairments and all kinds of deficits. And during that time, I had the chance to learn about the connections between cervical spine and temporomandibular disorder. And that was my way to that amazing and interesting clinical world.

[Jaz]
So the work you do now, how much of that is clinical? How much of that is alongside dentists and going on from that, what is the best way that dentists and physios can work together?

[Tzvika]
One of the main problems in the physiotherapy clinic is that according to the epidemiological findings data, we need to see much more temporomandibular disorder patients, but actually we don’t see them so much.

So, there is a big gap between the needs, the demand for patients with TMD and the match to rehabilitation, to musculoskeletal rehabilitation. I think dentists are the best professionals to close these gaps because dentists do see patients with TMD how they see them because they ask their patients to open the mouth.

And when you need to open the mouth, that would be the best screening for temporomandibular disorders, even without diagnosing the exact specific diagnosis. But you understand that there is something with the masticatory system, something with the TMJ, and that would be an excellent trigger to refer the patients to the appropriate physiotherapy.

So, we see that in different countries that I teach, such as Belgium, for example, I’ve been teaching in Belgium since 2017. And back then, six years ago, the physios did not know what is temporomandibular disorder? How can they get these patients? And while training physiotherapists and also training them to contact dentists, they started to get more and more referrals.

And now when I come to Belgium, to Brussels and to Leuven and to Ghent, they keep telling, they tell me all the time that it’s an excellent cooperation because they get, the dentists were looking for the clinicians that can help the patients and the physios were looking for the clinicians that can refer them to patients. So that’s an excellent match between the diagnosis and the referral. And the rehabilitation, practitioner.

[Jaz]
I totally agree. And with my management of temporomandibular disorders in practice, I don’t think I can get the results without the physio that I use. So hopefully she’ll be joining us when you are visiting the UK in December, Krina Panchal be joining us.

I’ve told her all about you. So, she’s excited to learn from you. And then, she’s learned from Rocobado and all these people around the world because just like you said, physios, it’s in the UK. And now you said Belgium as well when they come out of physio school. They’d learn from like the neck downwards, right?

They don’t learn about the TMJ, which is just a real loss. But I can see from their perspective, you mentioned that there is a disparity in terms of how many patients should be seeking care from physios compared to what they are. And I think dentists are indeed the link we should be recognizing that physios are in a great position, those who are trained in it are in a great position to help our patients, and we’re going to get better results, patients being more comfortable, less discomfort, better mouth opening, all those things that we want from our patients when you work with a physio.

So, yeah, I strongly believe there should be a synergy between dentists and physios. And you told me recently before we hit the record button that you were in Hong Kong and a lot of the delegates, I attended weren’t just physios or healthcare professionals, there were dentists as well, which I think is amazing. I think we can learn so much from each other by attending sort of each other’s sort of educational circles. What kind of things were the dentists in Hong Kong interested to learn about from you?

[Tzvika]
I think there were two main things for them is one is to understand the specific diagnosis of patients with temporomandibular disorders, not just to know something is wrong with that system.

But to understand exactly based on the available evidence, yeah, the body of knowledge that we have, what is the specific diagnosis? And secondly, what can physiotherapists offer patients with TMD? So, what can we actually offer? And what is the prognosis? How to cooperate with the physical therapist?

So, these were two main things and it was very interesting because in the first day, it was a day for more for the diagnostic component. They were really up to it and wanting to understand everything and be part of doing that. And in the second day, they were just observing the physiotherapist, just mainly observing how physios can actually approach with the hands on.

We had some case studies there, so they were impressed by the ability of the physiotherapist to improve range of motion very quickly as to stretch muscles to understand the connections to the neck, to the cervical spine. So that was very nice to see that there in the first day, they were the one to lead this circle or this combination of cooperation.

And the second day they were just observing and really interested in how the other profession is treating, is rehabilitating the patients. Yeah, so in Hong Kong, it was a very interesting cooperation because the course is divided into two main topics. The first day is more about diagnostics and the second day is more about rehabilitation.

So the cooperation was very nice to see that in the first day, the dentists were the professionals to lead the day, to be part of the diagnostic seeking to the diagnostic criteria, understand the specific diagnostic differences. And in the second day, they were more watching the physiotherapist in action, the ability of the physiotherapist to improve the range of motion of their patients of the case studies that we had in the course, the ability of the physiotherapist to recognize cervical spine involvement, to understand how the neck is affecting the temporomandibular joint.

So that was very nice to see. And also, that the dentist in the first day could actually contribute to the physiotherapist about understanding occlusion, understanding malocclusion, understanding the skills of diagnosing some observing into the mouth. Yeah. Intraoral therapy, palpation inside the mouth. So that was a really nice knowledge sharing between the two professions.

[Jaz]
Yeah, I would love more of that in the UK, and I think hopefully we can spark something with your visit. We’ll talk about that later. Let’s talk about a sign, right? There are symptoms and there’s signs. And one of the signs that the patient may be suffering in the masticatory department the stomatognathic system, the TMJ is a limited mouth opening.

So just cover, for the dental student and going forward to dentist building up. What kind of mouth openings is a normal range of movement, including opening wide and left and right lateral. And then what point do we think something’s going on? And then as we talk about that, we can then try and discuss, okay, it is more muscular intracapsular and how you approach these issues.

[Tzvika]
Well, a functional range of motion is considered 30 millimeters and more, and a normal range of motion is considered 40 millimeters and more. In terms of protrusion, protrusive movement, we want around the 10 millimeters. And a lateral exertion, side to side, we want 5 to 10 millimeters. You can see that asymmetry is sometimes suggests a disorder, but not always. So, some healthy controls may present asymmetry in mouth opening, but if the asymmetry is associated with pain and with limited opening, that would be a significant issue usually. And-

[Jaz]
By asymmetry, Dr. Greenbaum do you mean like deviations and deflections?

[Tzvika]
Yeah, yeah. When you see someone, the opening pattern of a patient, when it’s not straight, most of us actually are not straight. So, it’s quite acceptable to see someone that is not opening completely straight. But if it is associated with limitation of movement and pain, then usually that will be clinically relevant. But if it’s just asymmetry and the patient open wide, more than 40 millimeters without pain, probably it’s just a sign and not a symptom. And many of us, more than 50% of us, are presented with signs. Luckily, only a minority of us presenting symptoms.

[Jaz]
But do you think there’s a merit in checking this in our patients so that we can be aware of the sign and see, can we perhaps give this patient some advice, recommendations to prevent this becoming into so bad that it then becomes symptomatic for the patient in the future?

[Tzvika]
Well, if you see a patient that can’t open more than 40, even if he has no pain, I would say specifically if it’s an older patient, I would say this patient needs to train the musculoskeletal system in order to prevent degenerative disorders. So it could be that if the patient is deteriorating from 40 to 38, 37, and in your checkups, when you take this measurement and you can see a trend of deterioration, for sure that this patient will benefit from physiotherapy.

And also, you can instruct the patient to improve the range of motion quite easily. But you need to know how to do that. So that would be something very quick to learn in the course, but it would be something that you need to prescribe in an accurate manner.

[Jaz]
And the most common time where we struggle as dentists is restorations in the back of the mouth, doing root canals, crown preparations, fillings. And the dream patient is someone who can open 50 millimeters plus, okay? But there’s very few of these dream patients, right? Sometimes you get these men, and they can open just huge. And then you can have your hands, both your hands inside, your nurse can have two hands inside. And it’s just, that’s the best way to go.

But unfortunately, many of our patients really struggle. Now I’m a big fan in general. I’m a huge, huge fan of placing a mouth prop or a wedge in the patient’s mouth. Because I said, what I say to patients, Dr. Greenbaum is, is the difference between you holding your elbow out like this. Okay. And letting that muscle tire versus leaning on something.

Okay. And it’s the same if you’re stretching open, okay, you’re using all the depressor muscles and they’re having to work the whole time as your patient’s open. If you can give them a wedge, the way I sell it to a patient is, allow you to relax into it. I need to relax and that puts them in a relaxed frame of mind.

The language you use is also very important. So that’s how I can help my patients to be more comfortable and get some mouth opening. But sometimes their mouth opening is so difficult to, you struggle. They struggle to even hold a wedge. So for a lot of our colleagues, we want our patients to be able to open a bigger.

What advice would you give the dentist to help our patients to be able to open better, not only for their functional requirements, but to allow us to do our dentistry?

[Tzvika]
First of all, I would be a cautious with the patients that are sensitive. So one specific group within the TMD, which is a pain related group. These are patients that are more sensitive to pain and with these patients, you need to be very careful because if you facilitate or elicit a pain response in their treatment again and again and again, the chances for them to develop a chronic pain disorder is quite high.

So, with this patient, I would not push them too much, but the other, the vast majority of patients. Like any exercise program, a gradual training for mouth opening with extra help of the hands like a stretch, self-stretch, I would just demonstrate it, with some extension of the neck, because the extensors of the neck provide a lot of force and web space can support between the lips and the chin.

[Jaz]
So just to describe to the audio listeners what Dr. Greenbaum was doing is he was opening big and then using the two hands as if he’s choking himself, but he’s choking just below the lower incisors basically. And then he’s giving the extra few millimeters of stretch while you are tilting your head backwards.

[Tzvika]
Yeah. and then you get some force, you get some strength and force from the neck to increase the leverage to open the mouth because you need to overcome a very tight muscle. The closest they can develop up to 90 kilograms in male and up to 70 kilograms in female. In order to overcome the tightness, you need to use a fair bit of strength. And just opening the mouth is not enough to get some overpressure, external overpressure from the hands and from the neck can help quite a bit.

[Jaz]
And how often would you advise your patients to do this before the appointment so that you can get some sort of extra four or five millimeters, which would be good for the patient in general in their function, but in terms of your treatment. So, what is the kind of regime that a patient would do?

[Tzvika]
If the patients are physically fit and they do stretch themselves and many patients do that today. I would recommend it as part of their routine. So, when they stretch the hamstring, stretch the low back, stretch the upper trapezius, et cetera, they need to remember to stretch the most closest as well, because this muscle group is very tight.

It’s anti-gravity muscle because they always walk against the gravity, and they tend to get really tight. So as part of the routine for my patients that are also a sleep bruxist, so they clench the teeth during the night, that would be the first thing in the morning. So, before they brush their teeth, I recommend them to stretch it for 30 seconds twice, 30 seconds, and just to have a nice start of the day after a long tightening of the muscles during the night.

[Jaz]
Absolutely. What I find is my patients who are both sleep bruxist, but also awake bruxist, right? They spend so much of their time. with their masseters and temporalis, everything in a contracted state, right?

Everything is shortened. Everything is contracted, right? And I can only imagine all the lactic acid building up. Is that still an accepted theory? The lactic acid, the buildup of lactic acid in the muscles?

[Tzvika]
Yeah, it’s a fatigue-ability of the muscles. So we are at the, there is a change in the physiology within the muscle. If you take any muscle and you work. Keep working it on a lower level, but for a long period of time. That would be the recipe to have pain. Because the muscle gets the oxygen level gets low, and the carbohydrate gets higher, and then the physiology of the muscle, that becomes a sick muscle. On the other hand, if you do it at night, that would be an excellent recipe to build up the muscle mass.

That’s why the sleep bruxist, they would be hypertrophic, and the awake bruxist, they would be atrophic. Because when you do it during the day, and you do it for a long period of time, and it’s associated with pain, you start to lose the muscle mass. But when you do it at night, in a phasic way, so you do it in cycles. That would be, and you do it and then you relax, you do it, and then you relax, then you build the muscle. Of course, we don’t want it so much.

[Jaz]
It’s the dental gym, right? It’s the dental gym, yeah. And it’s these hypertrophic patients that crack teeth. Dr. Greenbaum, they crack teeth and they put our restorative materials and a lot of stress and strain.

[Tzvika]
It’s a gym for free every night, but not advisable.

[Jaz]
Absolutely. I mean, it’d be interesting to know, because you’ve obviously done so much training, PhD, about if you believe that changing the external factors can stop bruxism. So there’s one theory that once a bruxist, always a bruxist, and it’s very difficult to try and get someone to suddenly stop being a bruxist.

They will still do some activity every night. Whereas, oh, if you just do this one therapy, or if we just reduce your stress, that you will stop bruxing. Anything that you’ve come across in terms of what you believe?

[Tzvika]
Well, let’s divide between the awake bruxism and sleep bruxism, because awake bruxism is a behavioral disorder with sleep bruxism is a sleep disorder, not necessarily they come together.

A majority of patients are either sleep bruxist or awake bruxist. So for the awake bruxist as a behavioral disorder, we can approach it in behavioral therapy and we can change the behavior, can reduce it. Having said that it’s associated with mental stress. So you also need to address somehow the mental stress.

Now you will not make these patients laid back patients. Yeah, the awake bruxist is usually their type a personality, but you can modify it a little bit. You can take the edge of it a little bit. The sleep bruxist is a different story. It’s a multifactorial phenomena. It requires some very accurate assessment for the sleeping hygiene.

It requires a sleep laboratory requires some screening for medication use, alcohol use, and sometimes there is something to do about it, but many other times is mainly protecting the teeth. And the Botox is actually a nice intervention for some of these patients to reduce the strength of these muscles, but awake bruxism, behavioral change, sleep bruxism, sleep disorder, different approach, two different approaches.

[Jaz]
Do you believe there’s anything that we can, for those dentists who want to help the patient stop the sleep bruxism, stop the sleep disorder? What do you feel that they could be doing? So for example, because this is something, if they’re doing more sleep bruxism, their muscles are tighter. Their mouth opening is less.

Like I give my patients occlusal appliances, but I color these occlusal appliances in. And I know that they’re grinding still, even though I’ve given them appliance, they’re still grinding on my appliance. I can see the proof. I can sometimes do lots of fancy dentistry, put all these crowns, get their joint within centric relation.

But they will still Brux, because I know A, on their appliance, but B, things like a Brux checker, which I use my patients and I see that, no matter how beautiful everything is, how balanced everything is, how the center lines match up, they’re still Bruxing because they’re removing the ink from the Brux checker.

So I’ve yet to come across the proof in my own patients that Intervention A will stop the sleep disorder. I’ve yet to find it, but that doesn’t mean it doesn’t exist. I’m open to the universe to learn. Is there anything that you’ve found from your research or from colleagues that has been suggested to limit, reduce, control sleep bruxism?

[Tzvika]
The literature speaks about sleep hygiene. So, getting into sleep slowly with no smartphones around, exercise, if you are exercising not very close to the sleep. Time to the bedtime, but to be honest, it’s a big challenge. I don’t see a breakthrough clinical intervention in that regard. Having said that we are researching today in our laboratory, the relationship between sleep bruxism and obstructive sleep apnea.

Because they have some tendency to come together, and we are testing the option that one of them is actually feeding the other. We believe we are hypothesizing that the sleep bruxism might be perpetuating factor for obstructive sleep apnea by activating the mouth closers and inhibiting.

The mouth openers, which are also stabilizing the base of the tongue. So what we want to see is if the patients with OSA, obstructive sleep apnea, that have also sleep bruxism, if there is some relationship between their severity of sleep bruxism and severity of OSA, and severity of mouth’s closest strength, and the severity of the obstructive sleep apnea.

So that’s another thing that we are trying to assess, but how to get rid of sleep bruxism. That’s a big challenge. That’s usually it’s just by time, after the age of 60, it drops to 3%, before the age of 60, something around the eight or 10% of the population. So maybe it’s just by natural course.

[Jaz]
The problem with that data, Dr. Greenbaum, with the percentages are completely, based on literature and I see that the issue with the data collection on those is, are often surveys of patients while they’re awake. They’re like asking the patient, but most of the time patients are completely unaware of their habit, right?

So my only issue with that data would be that I think that is underestimating the percentage of sleep bruxists out there. If you just look at, not you, but those who are listening, the work behind Giles Levine and looking at rhythmic masticatory muscle activity, 60% to 70% plus, there is a bit of movement of the masticatory muscles at night, which is rhythmic and that’s normal.

And so if you just look at that, if you classify that as a type of bruxism, then already it’s so much. I guess the ones we’re concerned with as dentists and you guys, well, rehabilitating your patients in pain is those patients who are taking something that’s normal, which is rhythmic masticatory muscle activity, and really going above and beyond what should be happening, and now actually causing stress in the system, muscles being upset, and actually damaging the masticatory system.

And so really to find out the true percentage of that, we need the studies, which we don’t have. And that’s why it’s a bit of a dilemma in terms of get that. Is there anything you want to add on that before I talk more about the regimes to help our patients?

[Tzvika]
We have today some clinical, we are trying to establish a diagnostic criteria for sleep bruxism, so it’s still not valid and reliable, but there is a consensus group with Professor Manfredini, Professor Winocur, and some other doctors in Europe and States that are trying to establish the clinical diagnostic criteria.

I feel that we have the ability to at least suspect that our patient is, is asleep bruxist, because the hypertrophic is one. The muscular hypertrophic, specifically unilateral asymmetry. So usually, they have a unilaterally of the side, but they do it on both sides, but one side is more. And then the spouse is also questioning the spouse about the noises.

That’s another important criteria. And then you can also observe the mouth. Of course, you guys, the dentists are excellent in seeing the erosion, but you can also see the marks of the teeth on the tongue and also the linear alba within the internal aspect. So I think when you combine these five factors, you can be quite suspicious that your patient is most likely to be a sleep bruxist.

I think that the muscle hypertrophy is very important. From my perspective as a physio, when I see a patient with a very dominant masseter in temporalis and also medial pterygoid from inside, I can observe when I see the hypertrophy, I strongly suspect that I have a sleep bruxist in front of me.

[Jaz]
I absolutely agree with you. And I encourage all dentists to check, Dr. Greenbaum, a lot of dentists, they get out of the habit of doing a muscle exam and it’s just so, so quick and easy for us to do even externally and just even just to feel the size of the masseters, the size of the temporalis, takes very little time and I think adds to your findings, adds to your diagnosis, even influences exactly which type of restorations I will do, which teeth I will crown, what my crown will be made of to withstand those forces, who are the high occlusal risk patients, who are the low occlusal risk patients.

So I think it’s absolutely fundamental. Now just to go back on track in terms of my patient can’t open their mouth anymore. You suggested that the exercise they do, is it just a once a day that we should recommend our patients do this or is it three times a day? Any sort of guidelines we can give and how soon along with other exercises, which you may go into, can we start seeing results from our patients so that we can have an easier time doing our dentistry?

[Tzvika]
First of all, for stretching, if you are not an athlete, if you’re not a specific athlete, so there is no limitation for stretching. You can say that the more is the better. If you are a contact athlete, like a football player, you don’t want to stretch yourself all day long because you need the muscle tonicity to protect you.

But if you are just a human being that is not a professional athlete, and you want to improve the range of motion, you can do it as much as you want, not into pain. Yeah, don’t cause pain, but a strong believer in a daily activity. So functional activity that encourage full mouth opening. So patients that have been avoiding a full mouth opening, because they just got used that they can’t open.

I would encourage them slowly to return to their, for example, if they were using to cut their, the apple into half. Then I try to avoid that. Stop avoiding that. Or stop the avoidance would be actually exposing the patients into stress. And this, I think, in my opinion as a physio, is the most important behavioral change is stop the avoidance and try to get used to think that you’ve been doing and stopped, been doing because of the limitation, but very gradually. So exercise first. And then activation in the daily activity cycle.

[Jaz]
Yeah, so the functioning is right and proper. And in dentistry, we call this guarding. Patients are guarding. When we get our patients to open, and just to check the mouth opening, they will open a bit. And then we say, can you open as much as you can?

And then they open a lot more. Right? And so patients are sometimes guarding, and so it’s important to get them used to, they don’t actually exercise that additional range because they’re so used to, I completely agree with you. So definitely to encourage our patients to do it. And as in the physio world, as you guys say, motion is lotion, right?

So it’s good, it’s good to use it. Now, how might this change? And so firstly, let’s talk about pain, sorry. If the patient is experiencing some discomfort. Is there any guideline? Like, sometimes I say, well, if you haven’t been stretching something for a long time, A, go gradual, but you might feel a stretch, right?

A stretch is a sensation. When you stretch something, you feel a stretching sensation. It’s not the most pleasant thing in the world. It’s not the worst thing in the world either. So I think it’s important to expect a little bit, but I say, if it gets more of a six out of 10, then stop doing it. Basically, don’t go beyond that limit. Find that safe limit for you. Any guidelines on that?

[Tzvika]
Yes, I totally agree with you, I think that we need to reassure the patients to tell them up to that point is okay, so 5 out of 10 I would say, up to that is fine, more than that is not fine, and specifically what you feel after the stretch. If you feel after the stretch that you’re still in pain, it means you did too much, but if one or two minutes after the stretch you feel normal or even better than before, that’s a very good sign.

So I tell him not only during the stretch, but how do you feel a quarter of an hour after the stretch? Do you feel well after that? You should feel better. You should feel. If you feel more pain after the stretch, maybe half an hour, or if you can’t activate your musculatory system after the stretch, that means you did too much.

That means maybe there is a disorder that requires a rehabilitation. That means maybe there is an obstacle, a mechanical obstacle that a well-trained physio need to diagnose and help you to overcome.

[Jaz]
Well, let’s talk about that. So, what if a patient has got not so much muscular, but they’re having intracapsular issues and they’re getting locking and perhaps we need to focus more on that.

So, if someone’s trying to stretch open and they’re getting a pain in the preauricular area and the TMJ area, how might your rehabilitation change for that patient? Or certainly from a dentist perspective, we know that, okay, just because we get their muscles happier, they’re still the disc displacement to deal with. So what advice would you give to the dentist to help our patients whose diagnosis may be not purely muscular?

[Tzvika]
Well, the discogenic patients are more complicated because the potential to irritate them is very high. And the inflammatory potential is higher. With the muscular patient the inflammatory potential, the irritability is not very high.

But with these patients, we need to be very careful, specifically if they have intermittent locking. The patients with intermittent locking, they are unstable, and these patients need to be diagnosed well and need to be rehabilitated in a very accurate way, more in proprioceptive exercise. So more training the muscular compensatory factors.

But those who have this displacement without reduction, so that they are permanently locked, usually are more mechanical patients. And we can actually invest more energy in stretching depth. So we can actually go a little bit further with it. Intermittent locking, be careful with them because they are likely to have inflammatory response and the more this displacement without reduction of permanent lock and you can dare a little bit more to instruct them to stretch.

Having said that, this patient need to be rehabilitated by physios. I think that a dentist by himself should not be the only clinician to deal with this patient. So it’s exactly the synergy that we need with a rehabilitation practitioner and with a dentist that has a case manager and diagnosis.

[Jaz]
100% agree and I think a good guideline for dentists listening and watching to this it would be that if you have a patient who’s just got tight muscles and you’re just concerned that give them those stretching exercises.

And if it’s just a sign, not a symptom, then monitor them, but then maybe plant the seed in their head that, look, you might benefit, have you seen a physio before, this TMJ physios could really help you. And so let’s keep that, that we may be able to consider it.

If someone’s got displacement with intermittent locking or as a displacement without reduction. So they’re permanently locked. As you said, these patients, you really, really, really should try and find your local TMJ physio and work with them to rehabilitate this patient. You’ll really improve the quality of life, the patient, you’ll improve your dentistry because you get your patient to open bigger.

Which leads me to my final question. What are the kind of results we can expect? How much more mouth opening? Because I’ve read some papers. I’m very impressed, but guidelines. Now, how much more either as a percentage or as millimeters improved opening can we get from our patients who have physio assisted rehabilitation?

[Tzvika]
Well, if it’s a pain related patient, if we can professionally reduce their pain and their fear and the fear avoidance. We can improve them, for example, from 30 millimeters without pain until 50 millimeters without pain. So, 20 millimeters would be a very expectable result within few sessions. But if it’s a patient with an intrarticular disorder, displacement without reduction, with limited opening, that would be very gradual.

So if you improve them from 25 to 29 within one month, that’s a good success. That’s quite a good process of progress. With the patients with the degenerative joint disease, usually if they were untreated for a long period of time, it would take a bit more time to get improvement.

If they just started to deteriorate, then we can quite quickly improve them. So it depends how long they’ve been waiting before seeking for help.

[Jaz]
I think a good guideline for dentists is to start looking at your patient’s mouth opening. You can use a three-finger test, for example, as a very basic crude screening, but to get a ruler, it’s just so quick and easy as part of your new patient examination to do that, right?

[Tzvika]
Yeah, for sure. A ruler, we have no excuse to avoid the ruler. It’s so cheap. It’s so accurate. It’s valid. It’s reliable. The therapists that are taking my courses, they get it as a small present, small Israeli present from China because it’s all usually made by China. But I tell them you have to use it because it’s really simple and it gives you a very nice thumb rule if your patient is getting better or worse.

And the patient love it when they are measured. They love it because they see that you are monitoring them. They see that you care about their changes, and I strongly recommend to use it.

[Jaz]
It’s a bit like when we are doing a mouth cancer examination, which we’re doing a mouth cancer screening, right? If we tell our patients, hey, I’m going to do a mouth cancer screening, and then they go away thinking, wow, this dentist did a mouth cancer screening. I feel so good. I feel like I’m good that I was checked and that’s good. Whereas some dentists will do it, but they’re not telling the patient that they’re doing it.

So the patient never knows what’s happening. So A, it’s good to tell your patient what you’re doing. And B, this is just like that. If you tell, if every patient you see, new patient, Okay. And then recall as well. You just measure and say, hey, I’m going to measure your mouth opening. I’m going to see where you score in terms of normal.

And then it’ll be really good for me to check you over time. So I can pick up on any functional disturbances and look after you. Cause it’s something I’m very passionate about is the look, the muscles of the head and neck as well. And they’d be like, wow, this dentist is very detailed, very thorough.

No other dentist has done this for me before. They will get an idea that, yeah, this is a really good thing. So I would heavily encourage dentists to do that. The stretches that you recommended are great and also to pick up those patients who are perhaps a bit more involved in terms of intracapsular issues or degenerative and to really involve your physio.

That is the best thing you could do for your patient. Now I know that when you come in December, you’re going to cover a lot of this stuff the way I think you’re doing it I’m not organizing it, but I am partaking I’m supporting because I want dentists to learn more about TMD. I want physios and dentists to have more synergy in the UK because you’re visiting the UK.

So I’m assisting and organizing this course and I would like everyone, all the dentists listening to learn more from you. It’s a very reasonable offering as well. The way I suggested it is that you do live webinars on Zoom first. Because we want to have the theory in front on a laptop and catch up with the recording.

But when we come to the day, the much, as much hands on as we can do, and as much hands on that we can observe, that’s the best thing. So what kind of things are you looking to cover in this very bespoke special course that you’re organizing for dentists?

[Tzvika]
So we’re going to follow the acceptable diagnostic criteria for Temporomandibular disorder, the DCTMD.

It’s an excellent manual. It’s like a recipe that you follow, and you can get to the specific diagnosis in a UK, Canada, Israel and Belgium with the same patient. And it’s an excellent tool. So we’re going to cover that to learn how to use it and how to follow it and how to use the decision trees to get to the specific diagnosis.

So that would be a very important part. And then, according to the diagnosis, based on the diagnosis, we are going to understand the strategy to rehabilitate each one of the specific diagnosis, patients with a specific diagnosis, pain related, what’s more likely to be the strategy for management.

The intraticular and the degenerative. We will also learn how to understand if the neck is likely to play a role in the clinical presentation or not. That was my PhD. So I’m going to describe it and to present it and to show you in a practical way. A very quick screening to make a decision is the neck likely to play a role or is the neck not likely to play a role in the clinical presentation.

If it is, then of course for the physiotherapy very quickly, if not, you can keep managing the patient. Without considering too much the cervical spine. So that will be another component that we will discuss and train and practice.

[Jaz]
From teaching TMD courses. The dentist, myself, I found that a lot of time just to get the basic palpation skills is very important for dentists. Dentists often when they’re feeling like when they’re supposed to be palpating over the joints and the condyle, they’re actually more in the origin of masseter. And I also find that dentists are usually not palpating firmly enough. They’re a bit too gentle. So, are you going to be covering the more basic, as per the diagnostic criteria, exactly how to do the palpations for the dentists?

[Tzvika]
Yeah, part of the DCTMD is a calibration, is a calibrating the assessors. And it’s about how to build the stress on the palpation and how to consistently find the specific zones and area to cover the whole temporalis, the whole masseter, and specifically the TMJ. So definitely we’re going to specify the palpation skills of the dentist in order to accurately diagnose patients.

[Jaz]
Amazing. Well, we look forward to welcoming you. I will make it the show notes have the link that can click on. The website can easily make is protrusive.co.uk/greenbaum as G-R-E-E-N-B-A-U-M. So, it’s B-A-U-M, Greenbaum. And then that will take you to the landing page once you’ve had fully finalized it.

And like I said, I have no financial interest in this, except I just want education to be widespread. And I’m excited to come and learn from you. I’m excited for those who’ve learned with me, splints and stuff before to come and learn from a world expert physio. There’s so much we can learn and share with each other.

And I know you’re coming to do teach physios as well. But I think it’s a very special thing to organize for dentists. So I’m excited to learn from you further and also to allow accessibility for dentists in this event to get exposure and access to you as well.

[Tzvika]
Definitely. Yes. I think this cooperation is highly important from the few first courses I’ve given in the UK. I feel that the gap is really high. There’s a big gap to close in the favor of patients that having temporomandibular disorders. And that means the cooperation between diagnostic clinicians and rehabilitating clinicians is required and that would be an excellent start for us to be in this cooperation between the two professions. And I want to thank you personally for inviting me for this podcast. It’s been a real pleasure and great opportunity to share my knowledge with you.

[Jaz]
Yeah, thank you so much. And yeah, I look forward to seeing you on the 1st of December and hopefully much more from then as well as it’s great to finally meet you in this way. I know we had a zoom as well, but yeah, it’s great for you to share your knowledge. Thank you.

[Tzvika]
Looking forward to learn from you as well.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. Now, if you want to claim some CPD for this educational episode on the web app, for example, on your laptop, head over to protrusive.app or on your phone. If you already got the app downloaded, answer a few questions and my team will send you out a certificate.

If you’re a dentist who’s new into TMD and you’d like to learn about diagnosing TMDs and how we can work with other healthcare professionals to start helping our patients with temporomandibular disorders, and if you’re in the UK or even if you’re in Europe, come along to our event in December.

It’s not my event, it’s Dr. Greenbaum’s event, but I’ll be there to support him. It’s an area of dentistry that’s not as sexy as veneers and bonding, but it’s so, so important. It helps our patients to be pain free. So, if you’re interested in that, head to protrusive.co.uk/greenbaum, that’s G-R-E-E-N-B-A-U-M, that’s his surname, and I’ll make sure that redirects you to his event.

I hope to see some of you there. Otherwise, to all the podcast listeners, all the watchers, thanks so much for staying all the way to the end once again. I’ll catch you same time, same place next week.