3 Simple TMD Exercises – How To Prescribe Them – PDP111

Jaz’s Introduction:
The thing I discussed with TMD Physio Kreena Panchal today is that as dentists, we don’t really get taught exercises that well what the indications, how to do it, how many seconds to hold it for, because usually we ourselves learn it from Googling, finding a PDF, and following the images and just giving the patient the leaflet or a brochure and so that yeah, just do these exercises, you’ll be fine. But from this episode, we’re gonna make it super clear, super tangible. So you can start implementing this right away. Before we join Kreena, some important announcements that by time you’re listening to this, if you’re one of my listeners who listens on the day the podcast comes out, my superfans, the real Protruserati, thank you so much. There are just two days left to join Splint Course online, if you want to learn how to manage bruxism and TMD in practice now, the exciting announcement I have to add to that is that by the end of next week, the splint course will be available as a podcast. So it’s designed for the busy people who are commuting who don’t have time to watch the videos just yet. Therefore, even when you’re commuting, like you listen to this podcast, I’m going to let you consume the course, entire 13 plus hours as a podcast. And then all you have to do is refer back to the ebook, and refer back to the videos for the little clinical bits here and there. But you will absorb so much more just from driving and listening. So if that’s been, if you’re on the fence about it, because you’re gonna struggle to find the time but you always find time to listen to podcasts, then this is done for you so that you can access that information. And then you can drastically reduce the screen time you need to be able to get the knowledge that you need to start making splints on Monday morning. Now some of you email me saying Jaz, when are you going to bring the splint course as a live course because the online course really isn’t for me, well, good news and bad news, okay? Good news is that the live day is coming, okay? So me and Karina and a maxillofacial surgeon, we’re gonna do a live day. We’ll talk more about that later on the towards the end of the episode about what we’re gonna do, we’re gonna teach you, but the prerequisite is that you need to be a splint course delegate alumni, because if we did cover all the theory and the hands on that we want to as part of the splint course and I wanted you to really walk away with all the confidence that I know my delegates can get that it would be a three day course, that’s three days of lots of earnings, accommodation, etc. Therefore, I only want to do a one day hands on with a physio, myself and the maxillofacial surgeon to supplement the theory. It will be a little bit of a refresher as well. And there’s a beauty about live courses that sometimes you know, you really grasp concepts well when you’re there palpating, the origin the masseter where you are perhaps palpating in the wrong place all that time. So there’s so much to be gained from a supplement. But unless I did it into a whole three to four day course, it’s unrealistic to make it happen. So it’s a supplement only available to those splint course delegates, it’s just 200 pounds. Obviously, it’s in the UK. So I apologize to all my international delegates. But that’s another reason why the main course is still the online course. The most exotic delegate we’ve had so far in this cohort of splint course is from Ghana. So thank you, the Dentist from Ghana joining us from Africa. I think you’re the third African dentist to join the splint course. It’s great to have you. So because the Splint Course is international, it needs to be online. And I’m so proud of it. In fact, have a listen to the way that one of my delegates, Marwa was able to apply the splint course is gonna blow your mind, okay? Listen to how she was able to apply it.

[Marwa]
Yeah, it’s going really well. So I work. Half my week, I’m an associate just in general practice and half the week I work in maxfacts. So I’m actually applying what you’ve taught me in Maxfacst a lot.

[Jaz]
Amazing. Oh, Maxfacts need people who can..

[Marwa]
They need it.

[Jaz]
Who can really think outside the soft splint

[Marwa]
Yeah, oh my gosh, like very, very guilty of just giving soft splints to everybody. And like, I used to have a sense of dread because like, no one wants to see these TMD patients they get given to the most junior person on clinic which was me for a very long time. I used to dread it if the dentist really tried a soft splint because like, oh my gosh, what are we going to do? I can’t..

[Jaz]
You have no weapon anymore.

[Marwa]
I know and I’d be panicking and then conservative I eat you know nonsteroidals and just you know, see you in six months knowing they’ll never be seen again, unfortunately or not for at least two years just because of the backlog in the terrible system that we work in. So now I’ve got Yeah, got my own little clinic going and people are referring to me within the hospital because I’ve been made

[Jaz]
I’m so happy for you. Amazing. Oh, and what kind of, Have you found any failures there? Have you learned from any of these failures? In terms of diagnosis and stuff? I think you weren’t here earlier but what we were talking about the new form, the TMD evaluation form and one thing that I hadn’t really mentioned much on the course because not so common is people with masseter atrophies not hypertrophy, atrophy and the mistake I used to make in the past is okay this patient grinds let me try and ampsa and see if that helps them, these patients wouldn’t respond. Because obviously the whole point of ampsa is to dial down the muscles but with atrophy, you actually want to dial them up and I’ve learned a few things over time. So I’m gonna make some a bonus modules for you. But have you had, what kind of success or failures have you had so far?

[Marwa]
And so I guess last week, I just I had a fantastic successor, a lady that has been around everywhere she actually had ortho thinking it would solve her problem. It didn’t. And she was just fed up and she’d been see private specialists I think, trying to remember her if she had Botox or not, I think she potentially had tried Botox once but yeah, hadn’t reacted well to it, didn’t benefit her. And she was wearing like upper lower essix and I basically just converted one of them into an ampsa and essix with it, with the discluding element of splint. Sorry. And yeah, she literally came back three weeks later and was like, my pain has gone and she was just incredibly grateful and yeah, she’d been around ever so that was probably my biggest success because it’s one of those that literally has been to everyone, has been the orthodontist, has been to see other specialists, has been see other consultants, has had Botox I think privately and then little old me thanks to spplint course. And thanks for everything you’ve done

[Jaz]
Oh No, nothing. Oh, you did all the implementation. Honestly. It’s all I’m so so so happy to hear that. Well done

[Marwa]
Yeah, I’m trying to get the other team members on board and the consultants. The consultants when I presented this idea to them, obviously, they’re very old school, very much soft splint for everyone. And then when I said to them, you know, I’m learning about this, can I do this? I got two out of four of them on board, and another one came on board, and now he’s referring his patients to me, so they’ve got no interest in it. So but I’m very fortunate that I’ve got access to kind of MRIs I found a physiotherapist via ACP TMD, as you recommended, I can refer patients to on the NHS. There’s not too far from where I work. So I’ve been working with her as well.

[Jaz]
The Protrusive Dental Pearl I have for you today is a composite one, I know what you’re thinking, What are you doing Jaz? You’re mixing TMD and composites. But hey, guys, we’re generally dentists, right? We love this, we live and breathe this stuff. So my tip for you is this. Let’s say you’re doing a class four restoration in composite, and you’re going to be managing the interproximal area. Now, there’s so many different ways to manage it, now if you’re gonna be using the immediate way of managing. So it’s immediate and delay, and this is what Dipesh Palmer tips on the mini smile maker course, there’s immediate is okay, when you build your palatal wall, you are now immediately going to manage the interproximal area, the delayed would be you build the palatal wall, and then you start doing your veneering and whatnot. And then right at the end, you will manage the interproximal area however that may be. To manage it immediately. It usually will involve you using some form of an interproximal matrix for your class four, so sometimes we like to use a posterior sectional matrix vertically, right? You put us a posterior like SB 100, for example, or Tor VM. And there are some bespoke ones out there for those indications anyway, but you put it in vertically, instead of the horizontal way that you normally use it. And now you’re gonna place your composite to create that contact area, okay contact, so it’s not contact point, it’s a contact area. Now, the main tip here is I’ve been guilty in the past of just squirting with my capsule, the composite into that interproximal area, and then getting my burnisher on my brush and just sculpting it. But it’s not the best way, the better way would be actually. And I used to be really against this because I thought oh, you’re contaminating the composite, as long as you use a clean gloves it’s okay, so I’ve been taught. So you would take the composite on your fingers, first your gloved fingers, and you will roll it into a sausage, you will then place that sausage into the interproximal area as part of this immediate technique. The main tip here is how you handle the composite. And the reason that it’s a good idea to handle it in that way is that you’ve kind of halfway there and to get in the right shape for the interproximal, you want a nice curved area. So by putting something that’s already pre curved into a sausage in that area, it reduces the amount of work that you need to do with the instruments to get to adapt neatly to the interproximal surface. So that’s the main tip there. Use the composite in between your gloved finger, roll it as a sausage and put it there when you’re doing an immediate technique for class four. Anyway, let’s join Kreena and I’ll check you out in the outro.

Main Interview:

[Jaz] Kreena Panchal, Welcome back to the Protrusive Dental Podcast. How are you?

[Kreena]
Good. How are you?

[Jaz]
Amazing. I mean I say amazing. But we’re both parents. So we are exhausted. We are struggling, your little one is having a fever. My little one is with my parents because we’re afraid to send him to nursery in case he catches something before our holiday. So this is the sort of manic life that we live but I’m so grateful that you have time to speak again to the Protruserati. So guys if you haven’t listened to Episode 63 Please go back and listen because in that episode with Kreena, we discussed about the role that physiotherapist can have to help our TMD patients. What is it that you guys actually do? You mentioned a lot about Research, the opera study, for example, you mentioned, we went in a lot of detail into that. But today we’re gonna go a little bit more about exercises, the three main exercises, people, can dentists can listen to today, and have more faith, that they’re educating their patients better. Before we get to that, for those who haven’t yet listened to Episode 63, just introduce yourself, and tell us about why you love what you do.

[Kreena]
So I’m a specialist TMD physiotherapist. And I think I love working with TMD patients because they are so complex, no sort of rule or protocol fits all. There’s a lot of investigative work, I have the luxury of time. So I spend a lot of time with my patients, and therefore I’m able to do the investigation. So I just like how tricky they are to be honest. And so many different modalities need to come in for the treatment to work for the patient and how I’m able to work with so many different professionals and learn from them as well. So yeah, I really enjoy working with TMJ patients

[Jaz]
Where do you work? So obviously, lots of dentist message me all the time saying, Okay, well, who do I refer to? A lot of them have already listened to our episode. So they already know you and they refer to you and whatnot, but just give everyone a flavor of where you work. And then how potentially, if they’re not in your locale, how they can get some help from a local physio, maybe?

[Kreena]
Sure So, and I work in Mayfair in central London. And I also work in Gerrards cross, just outside of London, but I also do virtual appointments as well. To help, I’m able to assess them and give them exercises or teach them how to manage their own condition. Otherwise, you can go on the acptmd.co.uk website, under their menu, if you go on to find a practitioner, you’ll be able to find a local physio, who has training in TMD. From the physio hospitals out in up north, and there you say that can be your physio that you refer to and I would encourage you to get to know that person, maybe just have a quick phone call, see how the work, see how you can work together, so you’re both on the same page. And you’ll get referrals both ways.

[Jaz]
That’s so true. You know, the physios that help these patients with musculoskeletal issues which involve TMD can then refer to you where appropriate for an occlusal appliace for their mastication, restorative works, it definitely works two ways. And when I first found out about that website some years ago, I was working in Oxford at the time, and I found someone locally, we went out for coffee, I met this nice Greek man, unfortunately, he went back because of the pandemic, but the message here is connect, have a coffee, share the treatment principles, and then there’s definitely a mutual sort of relationship you can have in terms of referrals, and ultimately the patient’s benefit. So I would definitely encourage everyone to do that. Now Kreena, you are going to talk about some exercises. And the reason I wanted to bring you on to talk about exercise is because a bit like physios who in their training, they don’t get actually taught about TMD, which is when you first told me that that was fascinating. And you know, you’ve been around the world to learn from the best people, which I admire you so much, and I refer my patients to you. But when it comes to TMD, we know that there’s a mixed experience, even for dentists and the knowledge and information that we get at dental school, but exercises for sure we’re not very well taught. And in fact, most dentists will learn exercises by Googling them, finding a PDF, and then reading that information and then conveying it to their patient in front of them. So can you talk about what are the maybe two or three main exercises that you prescribe to your patients? What is the indication, the benefit for them? And how can I obviously lots of audio listeners here, but there’s video as well? How can you sort of describe it to them so that we can get better results for our patients?

[Kreena]
Sure. So when physios are assessing patients, you’re checking for their movement, their strength, their coordination, and then how all of those three link to their function. Okay? So the initial exercises that we give, are quite simple because first we want to assess their suitability with the exercise, the last thing you want to do is give them something and then everything flares up. So your assessment is key in there, if they’re already flat or so 10 out of 10 pain on the slightest touch, then, you know, you want to give really simple exercises initially. And it’s important to give them something because they don’t have confidence with on how to move, how to chew, how to function at all. So we need to initiate that movement and therefore start with them feeling confident that they can use their jaws, all of a sudden the discs gonna slip or they’re going to lock. So the first exercise is my joint exercise. And this exercise is where really simple, you can give it to everyone, even if there are 10 out of 10 acute flare up in their jaw joint, and super painful, I can’t do anything they’re talking with their lips, that sort of thing. They’re already on soft food diet, this is the first exercise to start with. So this is where we are doing pure rotation of the condylar head. Now, even though it seems like such a simple movement, when you are only rotating the condylar head, you are lubricating the condylar head, and therefore you’re getting lots of blood flow into that area. One of the reasons why whilst they’ve got pain there, but they will also have some inflammation there, and we need to be able to flush all of that out. So if they are not moving their jaw joints at all, specifically rotation, they are not getting fresh blood into that area, and that pain will persist and increase. So it’s really important that we initiate movement.

[Jaz]
And that’s a great thing. And also, I love this approach, you’re taking the Hey, everyone suitable for this exercise, because the classic mistake that a dentist might make, and I’ve made this mistake before is you see those images on that PDF with the exercises. And you just throw everything at that patient, like a, you know, spray and pray kind of thing. So it’s really good to start with this. And it very much follows a paradigm of motion is lotion. Because with movement, we are, the patient’s definitely worried to move it but that is contributing to their problem. That is, you know, the muscles are designed to move. So when they’re restricting their movement, that is not an optimum position biomechanically, so please tell us about the exercise.

[Kreena]
Yeah, so while you’re basically going to do is you describe it like this, you put your hand, if you do it with me, you will then know exactly how to do it. So you put your index fingers on the lateral poles of that your Condyle. And what you’re going to do is put your tongue onto the roof of your mouth. And that tongue, the tip of your tongue will not come away from the roof of your mouth at all. So we’re going to open and close our mouth, and we’re going to do it six times. But we are not going to do Snap, snap snap like a crocodile, we are going to count to about four for opening and count to four for closing. And ideally, and I insist, usually with patients that they do in front of a mirror, because they may have some deviations. And they don’t even know that they have it. Okay? So this is also an exercise to help you initiate and be aware of what normal movement is. Okay? So and so like I said, you do it six times, and you would do that then six times a day.

[Jaz]
Sure. And with the finger being at the lateral poles just in front of the ear. The rationale for that is that you don’t want to feel the condylar head, because that’s when it starts to translate. So that’s something you want to tell your patient that hey, if you’re feeling the bulge, you’re opening too big, right? So the tongue is one safety mechanism. The other one is for them to feel their finger that hey, they shouldn’t really be able to feel the condyle come out. And with them looking in the mirror, what do you say to when they have a deviation you tell them, Look, don’t worry about just yet? Or do you actually tell them to try and like some physios I’ve spoken to actually get the patient to sort of resist against that deviation? Where do you lie on that?

[Kreena]
I do give that exercise but later. So if this is my just the first go-to, get them moving, if they’re scared. And yeah, just basically, I would add the resistance in maybe next time I see them, if they come back and say, pain has reduced, the feel more confident they’re not talking with just lips, then I would then start adding the resistance in after but yeah, it’s really important that they are aware of what alignment. There are we.

[Jaz]
So this exercise indications any patient especially in pain, acute pain, chronic pain, this is going to help all your patients, which is great and get some moving fantastic. There’s no obviously contraindications to this at the very first sort of beginning. That’s a fairly easy one that we can all all of us dentists, we can prescribe this very much. So any more they want to add to this one or can we move to another one now? Maybe at a different level and a different approach.

[Kreena]
We can move to the next one. So the next one is my go-to muscle exercise. Because this exercise is basically an isometric strengthening exercise. And another name for it would be rhythmic stabilization as well. And the reason why I use this for my muscular patients is because their muscles may be in a lot of spasm. So if you go on to do really aggressive strengthening based exercises, it could flare them up again. So again, I’m assessing how irritable are there because because you know, you can do one thing for one patient, and he works beautifully, and you do the 10% of that thing for another and they’re in 10 out of 10 pain. So it’s really important to assess and you want them to trust you. So that I find that the first exercise and this one that I’m giving you, but 99% of my patients, there aren’t any flare ups, okay? So with this exercise, because we’re doing the isometric strengthening with it, what it will do is it will decrease the pain at the muscle that we are trying to strengthen, it will increase the range of movement of that muscle, but it also increases the blood supply within that muscle. And therefore we can flush out the lactic acid that’s built up there, which is usually the reason why they are complaining of the tension, at least that they are feeling, okay? But not only for muscular pain, but also if they’re presenting with just clicks or and just pops, you know, that is their only complaint, then this exercise is great for them too, because it stabilizes the joint. Because when it comes to isometric strengthening, you are contracting the muscle whilst the joint is fixed, the joint is not moving. So that means that we can strengthen the muscles around that joint and that stabilizes the joint capsule more and makes the muscles stronger so that you’re not clicking and popping constantly out of place and therefore is really good for hypermobile patients as well, which are usually the clicking and pop type patients because they over recruit their muscles in order to compensate for their increase in laxity of their ligaments.

[Jaz]
So remember guys, it was hyper because H-Y-P-E-R. So whenever someone says hyper or hypo, people always listen to it as such quick speed they sometimes misses a hypermobility, think of Ehlers Danlos as classic or other variety patients, these are the ones who often get quite open locks as well. And they are pretty much statistically known to have more disc intracapsular issues. So it’s great that you mentioned that but also on the theme of stabilizing, one of the tests that I like to do my patients I’m trying to figure out is this a joint issue, or a muscle issue is a stabilization test before you come on to the exercise. But let’s take a step back in diagnosis is I will hold and grasp their mandible, so the teeth are together, they’re pressing the teeth together, I’m keeping that mandible sharp so behind them, I’m actually bracing their mandible up against the maxilla. So teeth are now in maximum intercuspal position. And I’m getting the patient now to try and grind their teeth and try and protrude their teeth, all the muscles are firing, but I’m not allowing their jaw to move and henceforth, the condyle is not moving, the muscles are firing. And therefore if they have pain, or any issues here, it’s more indicative of a muscular issue than a joint issue because your condyle wasn’t moving. So that’s one thing there. So how are we going to use this principle here in the form of exercise? Please go ahead and describe it to us, Kreena.

[Kreena]
Sure, so I’ll explain it to you the way you would explain it to a patient, okay? So what you’re going to do is get your thumb placing on the bony part of your chin, you’re going to oppose opening of your mouth, okay? And the amount of resistance you’re going to put into that opposing force is about 50% ish of your maximum force. So it feels very light, you hold that for six seconds. Once those six seconds is over, you move over to one side of your chin, take your chin towards your finger. And then you oppose that movement again, hold it for six seconds, and you move to the other side and go over to the side again towards your finger. Oppose that resistance. And again, hold it for six seconds, and then you’re back into the middle.

[Jaz]
Just to make it really tangible, Kreena for those listening who are not getting the benefit of watching on YouTube because they’re in car mode or the chopping onions mode or whatever, it is, essentially, when you get the patient to grind left and right, you’re resisting that movement. Basically, you’re using the finger to stop them so they cannot grind in that direction.

[Kreena]
Yeah, so you’re you’re basically resisting opening and both lateral excursive movements, right? And you’re holding each one for six seconds. And then you would do that whole thing six times in one setting. And then you do that six times a day.

[Jaz]
Henceforth the name six by six.

[Kreena]
Exactly. So this is also good for those patients who are constantly playing and see checking something or wants to see how what their clicks like today or tell them to stop doing all of those things and do this exercise. instead.

[Jaz]
We had that patient recently on the the splint course support group. You mentioned that exact thing. That’s sometimes patients are keep testing about their click. And then it was actually the Protrusive Dental Community this one and Lakshmi, she was talking about the patient who on opening was, extreme opening was getting more pain in click. But I tend to think that okay, that’s more of an issue that there could be some hypermobility. And it could be like an open lock, as in the condyle can becoming beyond the eminence, so that patient just needs the advise to stop checking your click and stop opening so big because what part of the history was that when the patient yawns, that’s where an issue when it’s an issue. So if we don’t go as far as that range of motion, it’s going to improve and get better. And also by strengthening the muscles, you’re improving the future prognosis of it.

[Kreena]
Yes, exactly. Yeah, so this muscular exercise is a really good sort of go-to. And to be honest, if we’re looking at just the first session, then I would give the first exercise like I mentioned, and or the muscle exercise that I’ve mentioned. And I’ve the reason why it’s an or is because if I’m seeing that the patient is in acute pain, doesn’t really want to do much, then we stick to the first exercise, if the patient is presenting with always about, you know, five out of 10 pain, you know, in the background, then give them both

[Jaz]
Amazing. Now, can I be really cheeky Kreena and ask you for a third exercise, not that we’re going to be replacing physios because you guys are so important. And we need to be working as a team. But I think when we are prescribing exercise, you want to have more competence in that. And I don’t know, please tell me which exercise you were going to prescribe. But if it could be that the tongue scrape that we discussed in our recent monthly grind, because I find that, one of the most common emergencies that we see it as dentist is a spasm of the lateral pterygoid, in particular, and to stretch it, I think will really help the dentist. Is it okay, if we’re going that direction, but just out of curiosity, was there a different exercise that you were considering?

[Kreena]
Yeah, I was toying between that one and doing trigger point release. So I didn’t.

[Jaz]
I think trigger point release’s a bit more advanced. So let’s go for something that a dentist can apply really easily, advise our patients, and will help in a lot of emergency visits. So let’s talk about the tongue scrape.

[Kreena]
Sure. So the tongue scrape exercise is purely for the lateral pterygoid. And the way that we are basically stretching the lateral pterygoid. And because it’s such a small muscle, it’s quite tricky to feel you may feel I don’t really know what I’m doing here. But maybe if you’re in some pain, then you would be able to feel the stretch on your lateral pterygoid. If you don’t have a tight lateral pterygoid, you may not feel anything at all. So the way that you do it, is again, tip of your tongue, when you’re going to do is take it all the way back towards your throat as far back as you can, whilst your mouth is closed, okay? So that’s the first starting point, the number two is what you’re going to do is keep the tip of your tongue third back as possible, and then open. Okay? And close. But again, it’s not snap, snap snap, you need to do it really slowly. And to hold it for four and then close for four

[Jaz]
How much are we opening here?

[Kreena]
Until your tip of your tongue starts coming forward. If it starts coming a little bit forward, then stop that opening. Okay? so it’s very small opening and closing, because your tip of the tongue will probably start coming forward quite quickly.

[Jaz]
It’s definitely I mean, this is definitely within the rotation. And it’s not opening very much at all. And, you know, I’ve got a big slide. So I’ve got a very large horizontal slide so I can feel myself becoming more and more class two. Whereas with other people who don’t have as big of a slide as I do, they will not feel their jaw moving so far, posteriorly. But the whole point is that the lateral pterygoid is being stretched, because what you know, and this often confuses people who aren’t so into their anatomy, because the lateral pterygoid, the inferior lateral attaches to the condyle head and then the neck of it. So that brings the condyle forward ie protrudes. So we’re trying to do the opposite of contraction, we’re trying to lengthen and stretch hence why the direction we’re going is backwards just to cement that in the dentist head.

[Kreena]
Yeah, exactly. So yeah, so this will help reduce the spasm there. And this exercise again because you’re doing it in rotation. So say if you are presented with that acute pain patient, they are locked. You’ve given them the rotation exercise already. This is a nice one to give alongside that because it will help relax that lateral pterygoid and therefore release the disc hopefully as well.

[Jaz]
What do you advise on pain? Because I often tell my patients that okay, you know, no pain no gain some I’m okay with you experiencing a little bit of discomfort. I usually say six out of 10 but anything more than that, then maybe don’t go as far back or ease into it. Any guidelines that you give your patients? I’d love to hear.

[Kreena]
Sure, I’ll have two guidelines. Again, it’s about go back to the acute pain 10 out of 10 patients, those ones, and I don’t want them to feel much pain at all. And because they just they’re going to flare up and they’re going to catastrophize it potentially. So for those my guidelines is I don’t want it to be uncomfortable or painful at all. For those who are the five out of 10, muscular little bit of click that sort of thing, then yeah, around five, six out of 10 pain is fine. Anything more than that, then you need to back off. Also, I want their exercises to feel more stretchy, uncomfortable, rather than pain. So yeah, I usually phrase it like that. I’d say pain is bad at this stage. And it needs to be stretchy, uncomfortable.

[Jaz]
Great. I mean, I had a 19 year old patient recently who presented with some posterior open bites and acute pain, and my diagnosis was okay, there’s a degree of lateral pterygoid spasm here. There’s lots of, you know, malocclusion issues as well, I don’t want to go into a sponsor that debate versus malocclusion and TMD, that kind of stuff. But essentially I gave an Aqualiser sprint which we covered in the splint course and also in one of the monthly grinds, if you’re splint course delegate you go in you watch when the monthly grinds we talked about specifically that this patient and lateral pterygoid spasm basically made her a loom video of me showing the exercise and I showed it doing the tongue scrape as well as describing it with a tongue. I showed it with a ice cream stick like you know Magnum wooden stick and get them to sort of grind back onto that using that stick. And that’s a good thing to do as well and hold that position. And we’re able to within three weeks, correct her pain by 80% and get her occlusion back to normal look just confirming our diagnosis because sometimes our diagnosis is based on history and anatomy is our best guess. And sometimes, you know, there could be something more intracapsular going on, which becomes more apparent because although you’re doing all these muscle things, and then you’re doing everything to remove everything out the bucket. And I think what we’re does bucket come from? So this is where we’re going to have next Kreena, tell us about your bucket analogy, you came onto one of our Splint course monthly grind support sessions recently, and everyone loved your bucket analogy. So as a final piece here, can you please tell everyone about what is it? What would you refer? What do you mean by this bucket and how we can use that to assist our patients?

[Kreena]
So as we all know, the first session with a TMD patient is tricky, because there are so many things they are throwing at us. And we’re trying to work how rich, which ones are the top three contributing factors, causing factors. And we’re doing that through our medical examination, of course. But it’s also important to listen to what the things that they are saying, because usually those other things are aggravating them, right? It’s not just what they present with clinically. So my bucket analogy is basically, I gather all this information, and I’m looking at basically their sleep, their posture, their desk space, their stressors, that person that’s irritating them at work every single day, they happen to have a child that doesn’t sleep. So alongside the clinical assessment that I’ve made, and I’m thinking, well, this is the reason why I say they are clenching, say they are nail biting, I’ll put that into my bucket, then I’ll put in all the things that I’ve just said the sleep, the person, this kid irritating them, the child does not sleep at all that into the bucket and tell them that you’ve got all of these things are in your bucket, and they are contributing to the symptoms that you have. Now as physiotherapist or say, as a dentist, I can give you this to help with this. But you still have so many more things in this bucket that we are still contributing. So what can you do? Or what can, who can we refer you to, to help you with some of these things? And that way, ends up being a 50-50 relationship where I will do what I can from a physiotherapy point of view. Now what are you going to do to help yourself? Because this isn’t something that’s going to go away overnight, or I do six sessions of physiotherapy and all of a sudden you’re cured. And unless we take these things out of the bucket, we’re not going to be able to manage this condition for the long term, and it may come back again. So if we want to do manage it for the long term, then really let’s work on maybe we need to add some CBT and maybe you need to share the sleeping with your partner when you’ve got a kid that doesn’t sleep through the night. You know, all of these sorts of things. Lots of conversations need to be had. So when I say it like that, I find that other patients understand that it’s not just I grind my teeth, and if I could just stop grinding my teeth everything would get better. It’s not as simple as that.

[Jaz]
That’s why I love this analogy so much, because it’s useful to us as dentists. But when we’re communicating to our patients, there’s not just an occlusal appliance that’s going to help, there’s so much more to it. In all those things that you mentioned, it could even be cognitive behavioral therapy, as you said, so many different facets to it, including physiotherapy, and therefore it gets the patient on board that okay, although me as a dentist, I’m giving you some education, some exercises to some degree, I’m giving you an appliance. These are 3 of the 11 factors that we found in your bucket. So why don’t we look at the remaining eight things in your bucket and work with that, and the patients all be on board. And, you know, with conservative care and occlusal appliances, so many studies after studies after studies, and the range of successes from like 75 to 90% is around about 80% is the you know, to pull out the generic figure. But there’s still those 20% of patients that will need more, they will need more. And then sometimes they get more and more complex. And then when chronic pain enters a situation, that just becomes a whole new level, what would you say?

[Kreena]
Yeah, exactly. And it’s also it’s taking away that blame factor as well is that I got the splint or I did the physiotherapy and it hasn’t worked. But if in the first session, you’ve already explained the bucket, then they already are aware, they’re the ones are first come to you say okay, fine, I’ve had about three sessions, it’s not working, maybe it is the stress that you mentioned, maybe I do need to go and have some CBT. And so that you don’t need to then have that conversation, you’re not going to get blamed, they’re not angry or disappointed. They just know they need to move on to the next thing. And it’s just more, it’s a nicer relationship to have with your patient, rather than I’ve paid all this money and it hasn’t worked and then you’re stuck with what do you do next, you don’t need to be stuck, because you’ve got the bucket

[Jaz]
Kreena, I mean, that was absolutely brilliant. I know that dentists all over the world now will be able to help their TMD patients so much more. So thanks again for coming on adding so much value. But I think very excited to announce that we will be doing a live hands on day for TMD. And this is something that I think is going to help a lot of people above and beyond the online course. Because there’s so much more you can gain from actually hands on elements. So what kind of things are we hoping to cover on our live hands on day?

[Kreena]
So of course, we’ll do things like an anatomy. But I think it’s really important that we actually get hands on. So there’s one thing looking at a video of it. But there’s one thing actually feeling what a tight muscle feels like, palpating lateral part of a condyle when it’s inflamed, hopefully there’s some TMD patients there, they usually are find someone. And also to help calibrate the muscles, we’ll be looking at what a trigger point feels like. So I happy to go around and show everyone where their trigger points are, what it feels like, how we refers. And hopefully if we do it all together, everyone will be able to feel each other’s trigger points as well as everyone can describe where their referral patterns are, as well.

[Jaz]
I think the key word there for me is calibrate, you know, because to calibrate Okay, are we all doing the muscle exam correctly? Are we all putting the right amount of pressure? I get loaded and still asked me, Can you just make it really clear about the leaf gauge? Are we using leaf gauges? I’ll be making chairside splints on we’re gonna make some on each other. And I’ll show you how it’s done. We’ll pick someone we’ll go through the nuances of what the challenges, why that patient or that dentist that’s attending will be suitable for chairside appliance and why someone’s malocclusion will you be better with an indirect appliance. So we’re going to go over all that. But just to reiterate that actually, this is not a replacement for the online course, the online course is the foundations. And that’s why we’re pricing it as a very low, it’s just 200 pounds for to come along. But you should be a alumni of the splint course, because we assume then you’ve already taken some of that information on board, you’re already a little bit, you know, clued up about diagnosis and stuff. So this is just to fill in the little cracks in the voids, and give you that sort of confidence that when you’re clinically palpating your patients on Monday morning, you’re going to be better. So the dates for that is going to be eighth of May, and 19 to June. And I will email you probably in a couple of weeks to give the opportunity, going to be keep it quite small group sizes. So I’m sorry if anyone gets left behind. But this is the sort of there’ll be more opportunities in the future. But it’s about taking that one step further and adding a clinical day, a hands on day to what you’ve already developed through Splint course. So it’ll be great to have you there. We’re also getting a maxillofacial surgeon to come along, to talk about okay, at what point do we need to refer for surgery? And what is it that the surgeons actually do? I mean, I’ve got a really cool video on arthrocentesis I need to add on Splint Course still, but to find out what does that actually mean? What are the success rates? So that’s where the Maxfacts comes in. Anything you want to add to that, Kreena?

[Kreena]
No, I think just expect it to be incredibly hands on. Because like Jaz said, it’s not about listening to the theory of it, you would have already have done that, it’s going to be getting hands on and being really confident with how to diagnose a patient, and therefore knowing exactly what to then do when it comes to treatment as well. Whether it’s referring to a physio or whether is the which exercises are you going to give them and I know we’ve already mentioned my two or three go-to exercises. But those are the basics, there’s a lot more to add to that I will give Yes, I will give that rotation exercise but there’s a lot more that I tell the patient are more exercises, I also gives the patient a lot of advice as well. So you will get all of that information if you attend this practical day.

[Jaz]
Amazing. And I’m going to put your website as always in the show notes. So those patients or those dentists are looking to get an opinion from you, or refer a patient for your for virtual checkup or a real examination. Amazing, we can get that happened. So I’ll put that on the show notes. Kreena, thank you so much for coming on again, and just blessing us with so much information. I am so grateful to be a friend of yours and to have you in my circle. Thank you so much for adding so much value.

[Kreena]
Thank you. It’s been a pleasure as always.

Jaz’s Outro:
There we have it guys. Thanks for listening all the way to the end. If now is a time to add splint course to your list of courses that you’ve done, because you want to learn more about bruxism, occlusal appliances, which splint, when. Head on over to splintcourse.com. Hopefully you’re making time for enrollment. If not, don’t worry, there’ll be opportunities in the future. And for those who are already on to splint course and you’re waiting for the live dates and booking links, whatnot, don’t worry, I’m going to email them to you soon. So again, thanks so much for joining me all the way to the end. Now please do excuse me, if I am less responsive over the next week, because I’m finally going on a family vacation. So three years later, obviously pandemic and whatnot. And my son has never been on a long haul flight. And so we’re so excited. When last time I went to South of France, but I almost died. I had like some crazy thing in my throat and I had to like get this emergency flight back and almost lost my airway. And I don’t want to go into that. But I’m hoping for no health mishaps on this holiday. And so it’s our first proper holiday, we’re going to Dubai. So if I’m a little less responsive, please forgive me. I have always tried to make sure there’s an episode every week and there still will be even though I’m on holiday. There will still be an AskJaz episode coming soon. So I’m excited to share that one with you. Anyway, I’ll catch you soon guys. Thanks so much as always listening all the way to the end