TMJ Physiotherapy – When to Refer and How They can Help – PDP063

Jaz’s Introduction:
Hello, Protruserati. I’m Jaz Gulati and welcome to another episode of The Protrusive Dental Podcast. Today, I am recording this introduction on international women’s day. I’m so proud to be sharing this episode with a fantastic woman. Her name is Krina Panchal.

Krina Panchal is a TMJ physiotherapist and I’m a huge believer in physiotherapy to the management of your TMD patients. And I’m going to let her explain why it’s so important and how we can collaborate. So this episode basically covers when, why and how to involve a physiotherapist in the management of your TMD patients like I often refer to my patients especially when they have chronic pain.

Chronic pain is a completely different beast to someone’s got acute tmd. So chronic is like when it’s been more than six months and what happens with chronic pain is that they develop something called chronicity meaning that the the nerve signals that fire from the brain to the site of pain they get sensitized over time and even though that initial inflammation or strain it heals, the pain signals are still firing. So chronic pain is a completely different beast.

So we can’t just rely on advice and appliances, we need to involve a fantastic speciality of physiotherapy because they are really really useful for helping our patients who suffer from tmd. And if you’ve ever wondered how to get in touch with one, what kind of diagnosis they can help with then this episode will clear that out for you.

Protrusive Dental Pearl
The Protrusive Dental Pearl I want to share with you today is something I actually learned from Krina Panchal’s instagram. She saw a dentist who made her a brux checker. At that time I had no idea what a brux checker was. But it seemed really interesting like right up my street, on the theme of bruxism and parafunction so I did some more research and I learned a lot from her video.

It’s basically like a thin foil imagine like a really thin essex retainer like a foil and it’s red and what happens that when you grind or clench when your patient with parafunctions on the foil they make a little mark, they make a little pattern. So it’s helpful in diagnosing people who’ve got parafunction but more importantly which teeth touch and when do they touch?

It gives you that sort of diagnostic information, I mean in the literature for the brux checker it’s referred to as the ecg of occlusion and bruxism which I found very fascinating. So I made a youtube video about six minutes all about the brux checker giving my honest reviews because what I did is I tried it on myself, I tried it on my nurse, I tried on my patients and I have to tell you to give you a spoiler I’m a big fan right?

Like I’ll make it tangible, I had this one patient who came to see me because he wanted some bonding and he came to me as a second opinion because his existing dentist my principal was not quite ready to do some bonding on him because some other bonding kept chipping and so my principal thought you know what I think there’s some bruxism going on. I think you should see, Jaz, because this is the kind of stuff he deals with.

So he came to see me and I wanted to know the chipping that he was having on his anterior composites was it due to bruxism or not or was it something that was not bruxism related i.e the composite was too thin or something he was doing not at nighttime i.e was he biting on sellotape or biting his nails that kind of stuff.

So what I did is I made him a brux checker and I mean I had seen that he had signs of bruxism and parafunction so I knew he would create a mark in it. So he went home he wore it for me and then when he showed it to me it showed that at no point did he touch or go near the composites that we were concerned about and so whether he could he couldn’t have bonding on the premolars I think he could because actually it showed that he had canine initiated disclusion and he didn’t come onto the premolars which he wanted bonding.

So as long as the occluding scheme is respected and you conform to it I don’t think there’s any issue here in terms of chipping from bruxism because I think his bruxism is happening in all the right places. It was happening on the canine which didn’t have any bonding on them so this was a cool little thing to do and I’m hoping I’ve shared some of those photos with you for those who are watching on youtube to gain some value from that. So let’s join the episode with Krina Panchal on the importance of tmj physiotherapy

Main Episode:
Krina Panchal, welcome to the Protrusive Dental podcast. Our first ever physiotherapist and I am so pumped to have you on today. Thank you so much for coming on.

[Krina]
Thank you, thanks for having me. I’m very excited as well.

[Jaz]
I actually knew your husband Kartik from just social media and I think I met him in a course some of that and then when I stumbled across here when we started following each other on instagram. I was like wow this is amazing because I’ve been looking for a physiotherapist who niches into the temporomandibular joint for so long and i did find one but he wasn’t as good as you, Krina.

So I’m so so happy, the stuff you put out the content you put out the dentist and the surgeons that you are associated with in London is just wow mind-blowing like you work with some really top people in this field who also just love this area so kudos to you but before we just dive right in tell us a little bit about your background. I know already because we had a little chat on the phone but tell us how you as a physiotherapist ended up specializing within tmj of all things.

[Krina]
Sure. So basically we do our degree and you come out as a general physio. I guess I like general dentistry really and then you work for a few years and you think I need to specialize in something. Nothing was really taking my fancy you know like if I want to do musculoskeletal and neurological or specializing the knee and so and then I actually met my husband Kartik as you know he’s a dentist and and he introduced me to the TMJ and he asked me what can you do about it? And I said well actually we’re not even taught the tmj at university because we’re only tall neck down.

So we don’t even know what’s actually going on in the head which is ridiculous really because in other countries they are. Anyway long story short, I started reading about the joints and I thought it was really interesting. No one’s really treating it that well in this country in terms of physio, why don’t I do some studying on it?

So then a little bit of studying and reading turned into doing some courses. So I guess I went over to America first, Atlanta and there was a physio there he was doing a lot of recognized courses. So I did a course with him as Jeff Krauss then i went over to Columbia university in New York and they’ve got a head neck and facial unit there department where it’s full of maxfacts dentists, physios, psychologists and they’re very multi-disciplinary and they were basically all of them were treating these patients and I was able to see that.

So I did like a sort of work placement with them just to see how they work and then try and bring it back to the UK. Then I started pitching as a mini pitching to max facial surgeons and dentists and said this is what I’m doing. Are you guys interested? As I started working with the joint and then I went on to do some more qualifications with university of Liverpool. They do a master’s module called the differential diagnosis and management of the tmd and-

[Jaz]
That’s specifically for physios right? That’s not for dentistry specifically for physios?

[Krina]
Yes. The dentist can go on it if they wanted to learn more about I guess what we were doing and how we could work together and so I did that masters module that was about 2015. Then I went on to do something called crafter which is an academy based over in the Netherlands and it’s called it’s actually a cranial facial therapy academy and they teach about all the cranial bones, tmj, headaches, migraines tenses all of that.

So anything to do with the head, neck and facial region. So I did some courses with them then you know I went to Lithuania and did some Rocabado courses so for those who don’t know who Rocabado is and he is a very very experienced physiotherapist in Chile and he only treats tmj. He has lots of courses that he provides and he’s doing lots of research on this area as well.

So I did his courses to learn his assessment and treatment and then alongside that there’s all the treatment courses like doing pilates, dry needling, myofascial, taping laser that sort of thing. So it’s been a journey but-

[Jaz]
And now you work? Where do you work?

[Krina]
Yeah so and now I work over. I have a clinic in Mayfair and I have a clinic over in Johannes class as well. So I’m working there a few days a week and yeah I mean I don’t treat anything but head, neck and facial pain disorders. That’s all I do now. I don’t have any knees or shoulders anymore.

[Jaz]
Well I’m so excited to learn from you because I think we can make this a really really impactful episode for dentists because look the tmj is like this, it’s a dark art right like you said when as a physio you came out and they don’t teach you anything about tmj well yes we learn anatomy of tmj but ask any dentist okay and that most dentist ask them to draw you a temporomandibular joint okay and you’ll get a really, really, really, small drawing.

So small on purpose that you can’t really make out what’s right because we’re not confident on this, we’re not confident on tmj, we’re not confident in the management of clicks, we’re not confident on temporomandibular disorders. It’s a massive area that is only really delved into in postgraduate and even then there’s this class amount out there. So I think I’m so excited when I learn loads about from you today.

I first learned about Mariano Rocabado a few years ago then I learned about the Rocabado Pain Map now. Pain map now I think earlier on in maybe the episode six seven eight some of that i actually gave that as my protrusive dental pearl like you could download the Rocabado Pain Map and so it’s amazing when I spoke to you on the phone that you said that you had training from Rocabado and these great institutes and you’ve been chasing these institutions to to be really at the top of your game so that is absolutely amazing. So I’m gonna crack on and ask you the first question okay? So you’ve told us about your journey and niching down into tmj. Tell us what evidence is out there that physios or tmj physios are actually useful for tmd?

Like there is some evidence about like you know acupuncture and is debatable whether the evidence is good enough to say that acupuncture is good for tmd even the stuff on splints is abysmal like there’s a lot of evidence suggests that splints don’t do anything at all, other studies will show certain types splints will make things worse but there isn’t high quality evidence. So where is the stance on the evidence behind physiotherapy for the temporomandibular joint?

[Krina]
So evidence basically I think if we start with the nice guidelines which was published in 2016 by Andrew Sidebottom. He was one of the authors and he’s a maxillofacial surgeon, he specializes in tmd in terms of surgery. But actually I’ve spoken to him recently actually and he does not advocate surgery for tmd at all and he would rather that these professionals deal with patients who have tmd.

So that would be a dentist first you guys already know what you guys do and expense but then also it’s important to know that psychological services like cognitive behavioral therapy is really important as well because there is always a psychological distress in these patients and anxiety.

But then also lastly this is where I can help him is with physiotherapy and they’ve collated a lot of evidence to show that physiotherapy in especially alongside splint therapy works better because if you imagine when you have a splint the patient doesn’t have relaxation of muscles instantly it takes some time. Plus they’re not wearing it during the day. Usually you know they’re giving instructions to wear it in the night time and there is something called daytime bruxism where people are clenching habits during the day as well.

So that’s where physiotherapy can really help because we can actually relax all of those muscles and give them exercises and try and just help alongside splint therapy as well. And then the other guidelines that we use as well is by The Royal College of Surgeons of England where in 2013 and they recommended physio as long-invasive treatment instead of having surgery and trying that first before they go and do any irreversible treatments really.

And then I searched for systematic reviews rather than individual journal articles really and in this systematic review in general rehab 2010, they found that there’s already some evidence following and that the following can be effective in alleviating tmd pain and that was occlusion appliances, acupuncture also then draw exercise and postural training which is what I can help with.

[Jaz]
Amazing. Do you want to show some more? We’ve got loads of evidence.

[Krina]
Yeah and then after post-op surgery procedures and said that physiotherapy was really important in achieving good results again another and systematically saying physiotherapy is useful and then- [inaudible].

[Jaz]
So that’s amazing and it looks like there’s plenty of evidence out there that you guys are an important part of the team. I don’t think enough dentists refer to their physiotherapists enough and I think there’s a huge benefit and to the extent that yes I knew about in the UK, we had the ACPTMD like this is where you can find a locally trained tmj, a tmj physio if you like I struggled to find one that I could, that was close enough to it to my patients that I could really have a chat with.

And have a connection with so actually I took it upon myself and I hope you don’t take offense by this, Krina but actually read up and I’ve learned a few of the exercises that you guys prescribed and some manipulations that I started to do to help but now that I found you, Krina, you’ve already had one referral for from me already last week.

So I’m definitely sending them to you because you’re the girl who knows what to do but I think every dentist can learn a few things so that if their patient will take some time to find a physiotherapist that a few simple things might be able to help their patients. So I think it’s great and I’m so glad that like I said I’ve found you. I’m very very grateful for that and of course for this episode. So you’re going to share so much more. So we’ve talked about the evidence, what do you think and I’ve just switched over the questions a little bit Krina, is of all the things, what is the biggest etiological factor for tmd? What do you think in your cohort patients, what’s the biggest ecological factor?

[Krina]
So this as you probably already know is a very big question. I can’t really say that there’s even one or say there’s the top three but there is some evidence out there. So this is the OPPERA study which basically means oral facial pain perspective evaluation and risk assessment. And this was released in 2011 and what they did it was based over in America and what they did is that they recruited about 3,000 tmd III participants. All aged between 18 and 44 men and women equally and they did lots of physical examinations, filled out questionnaires, had tissue samples collected and they agreed to having follow-up re-examinations and questionnaires.

And what they basically found was that 3.5 to 4% of those 3 000 participants actually developed tmd. And then what they wanted to see is what were the risk factors and what was causing them to have the tmd. So they actually found that the incidence of first onset tmd was three times higher if someone had IBS. It was twice as high for people who reported lower back pain three times as high if people reported genital pain which is a bit vague but that was interesting and those who had tension headaches, it was also sort of associated as well and as well as fibromyalgia, fainting, insomnia.

So what this actual study is showing if you look at the flowchart, if you look at the pink part at the bottom that’s basically telling us that genetics is involved with tmd where everything is subject to genetic regulation for whether something is upregulated or downregulated. Then it goes on to say that high psychological distress is also related.

So most patients who have tmd will have some sort of psychological and distress and that could be depression, anxiety, mood disorders. But then what was also interesting is that with the purple area where it’s got the high state of pain, they basically had a decrease in pain inhibitory pathways and an increase in pain disintegrated pathways. So they were prone to actually feel more pain because their physiology was programmed that way.

And all of that is then also subject to the environment that you are in. So if you live in a certain area for example if you’re in London you have very stressful life with commuting or the pandemic is going on that then adds to whether you would get tmd or not and all of this contributed to the onset or more importantly the persistence of tmd.

So then to find actually one ecological factor is actually quite difficult because it’s so multifactorial and what I usually find with my patients is that there’s so many patients who brux for example and some are not in pain at all and some have a little bit of teeth wear and actually they’re in 10 out of 10k and what is it? Because they may have loads of psychological distress and you don’t know what genetics are like an environment may be super stressful as well you know why they are not in pain.

And I think really what it comes down to is something called adaptive capacity where is their ability to adapt or cope or how many physical revolutions they have determines their threshold to actually developing tmd.

[Jaz]
Krina, I totally agree. One of the splint episodes actually I talked about this as well about. I talked about two things: the adaptive capacity and you’re totally right. Resilience is such a great word to use there and the other thing I talked about was the weakest link theory is that you know some people their weakest link might be the teeth or the periodontitis, that’s why the teeth are loose. For other people their bones are hard, their teeth are resisting it but all sorts of damage is happening in the temporomandibular joint. But the theory I used to have Krina, some years ago is that I used to subscribe to this theory, very dentist based like we think that if there’s true trauma that would result in pain for example.

My background is I thought temporomandibular joint disorders were caused by micro trauma and macro trauma. So macro traumas like a punch to the jaw or a road traffic accident or a brawl on saturday night or a micro trauma would be the clenching, the grinding and the pen biting, the nail biting but the problem with that, Krina I’m sure you’ll agree with me here is that’s a very biological model i.e this trauma hence that causes pain and problems.

But I’ve since learned that pain is so complex and this is why I treat my chronic pain patients with tmd very very carefully and from now on you’re going to be seeing all my chronic pain patients because they are tough because pain like just like you said in Dentistry we were taught that how you feel pain varies by a factor of four. So the same injection that we do an id block for example one patient in the same technique we’ll say that’s a two out of ten pain, the next patient can say the same input is an eight out of ten pain and that’s a real pain.

So because pain is so complex because as you said the adaptive capacity can vary so much that is a huge part and it’s not just biological. Now it’s the bio psychosocial, have you come across the bio psychosocial model?
[Krina]
Yes. Basically I mean that’s one of the core modules when we do physiotherapy as a degree and we have to work in the biopsychosocial way and that’s why I think the OPPERA study is so important for tmd because it actually showcases the biopsychosocial model and urges all practitioners who are working with tmd to actually look at these things.

And it’s not just a case of just looking at the joints or just looking at the masseter and doing botox for example there’s so many other things that you should be looking at and it takes time if you’re treating a tmd patient to have a quick 10, 15, 20 minute appointment is never enough. I don’t know if you think the same, Jaz but-

[Jaz]
These patients drain you. I mean this is why I actually said in one of my first episodes i did in the splint series was like hey you know what? Don’t refer me to your tmd patients. I don’t want to see them no offense, I’m happy to stick to my orthodontics and smile makeovers and general dentistry. I don’t want to be bombarded with tmj patients. Learn to treat your own because they’re complex and one of the other things that we haven’t mentioned yet but I know you’re going to come on to is even their sleep quality can be important because that’s all related to the pain and everything. So this is all their sleep apnea whether they have that and how well they’re exercising and you might have listened to the back pain episode I did with some physios?

[Krina]
I haven’t. No. That’s the one that I haven’t listened to yet.

[Jaz]
Oh you might like it though. You’ll be like holding the whole way through these are really cool physios but I’m so glad i’ve got you on today for the tmj. Is there anything else you want to tell us about the OPPERA study?

[Krina]
No, that was just it. Just the fact that it was psychosocial and it’s important to take all of that into consideration.

[Jaz]
Perfect. So Krina, what’s the number one thing that you treat i.e what’s the most common diagnosis you will make? So for example dentist listening we have these diagnostic terms we use like for example now hopefully we’re not just writing tmd for everyone because that’s so vague right? But that’s what a lot of dentists do like you know diagnosis: tmd. There’s so much more to it than that.

So within tmd there could be intra-articular, there could be muscular, there could be all sorts and you know I’ve shared ones for the different classification system is very complex but what’s the main diagnosis that you see?

[Krina]
The main diagnosis I see would be myofascial pain, usually referred from the neck to the face or vice versa. Now I think maybe if I explained what my facial pain was a little bit. So basically what ends up happening is that you get myofascial pains, trigger points within muscles but what’s a trigger point? So a trigger you have a muscle okay and it’s made up of fibers and they’re in nice straight lines right? And then when you want to do a contraction these fibers come together and when you want to relax the fibers are apart. But usually with someone who’s got tmd for example in their masseter or their pterygoids. their muscles, their fibers are together like this because they’re contracted and in sudden but then they’re slightly twisted as well so then during function if you’re trying to open or close or use the muscle it’s hard for the muscles to come apart.

So then you’re only using the other fibers that are left surrounding, this trigger point to then do the work for you is the muscle is not as effective. But what actually happens at this trigger point because the trigger point is in the middle there where the neuromuscular junction is and effectively in simple terms, it’s a knot in these ones that you can feel in your masseter. What actually ends up happening there is that you get a local inflammatory response to a small level.

You wouldn’t get swelling there but there’s inflammation there and then you end up with a loss of oxygen and lots of nutrient supply and the shortening of fibers which is why you’re also contracted and that creates the trigger point in that area which is the knot okay and now you can have active trigger points. So that’s where maybe if you’ve been for a massage somewhere and someone really digs deep into your knot and you’ve got that sustained pain, what you can sometimes feel is that of course you’ll feel pain where they’re pressing down.

But then you may feel pain somewhere else and you think well that’s so far away from where they’re actually pressing that is what myofascial pain is where you have a knot in a muscle up but then it is referred to another area. So then when it comes to tmd specifically if I share a slide here. So this is basically so if you have a look at the masseter you can see that there’s a trigger point within the mass I mean there’s lots of trigger points that’s just one but you can see in red where it refers to.

So it actually can refer to the tmj joint within the ear so a patient may present to ent for example and say I have ear pain and then if you can find nothing because actually it’s coming from the masseter for example. Pterygoid is the same refers to the ear but then if you look at the other three pictures where you’re looking at the neck and the neck muscles and really these are where if someone’s got a forward head posture they’re going to have trigger points in these areas so they scan sternocleidomastoid trigger points within there refers to so many parts of your head and face area so this is basically one of the main areas that I treat.

And then in terms of treatment what I would usually do is find where all these trigger points are of course, note all of that down but then I do something called dry needling which is specifically for myofascial pain where it’s the same needle as acupuncture needles. It’s based on western medicine rather than Chinese. It’s just the same needle and I’m basically putting the needle into the knot so instead of using sustained pressure I’m putting down on the knot and I’m putting the needle in instead.

And what that does is a few things, increases both flow into the area but also because basically I’m putting the needle in and I’m causing microtrauma there. And then that then allows us to heal ourselves in that area and it realigns the fibers so rather than us being so twisted like this the fibers are able to be apart okay and separated but more importantly they are now over here which means they are in a relaxed lengthened position rather than contracted.

[Jaz]
What would cause, you know you said just now sternocleidomastoid is the most common muscle you get, did I interpret that correctly? You said that’s the most common area you treat?

[Krina]
Well yeah as well as probably the tweezers and some obstacles as well.

[Jaz]
Okay so subacceptables trapezius and steroid mastoid so why would cause it? Is it postural related, is it anything that people are doing that’s causing the knots to happen in the first place if you know what I mean?

[Krina]
So it will be sustained postures so it doesn’t necessarily have to be forward head posture it can also be that you may have great posture test work and they have great posture chair, great desk everything but maybe they’ve got several screens and they’re just looking to the screen onto the side constantly and to maintain that position is what then can cause a trigger point. So like dentists for example like I see every time I go to the dentist and my husband as well it’s like they have loops but they’re in this position for such a long time and he has loads of trigger points. So it’s sustained positions, it’s not always poor posture. It’s a more sustained position. We’re not made to stay safe so still.

[Jaz]
It reminds me of what the physio guys shared in the physio episode, Matt and Sam they said your best posture is your next posture i.e keep moving which I love always. I always remember that movement is a healing agent. And I love what you guys do the physios you know you guys really have got that all just so it’s just it’s great movement is medicine you know that the whole saying itself it really gets your patients thinking.

And what I learned from you guys is that quite a lot of times patients because of the initial acute pain they had which then turns into chronic pain and their muscles they sort of almost enter an avoidance pattern they’re avoiding, they’re bracing, they’re not using the muscle and then that makes things worse and then oh I’m only sticking to soft foods but really what I learned from you guys so far is that they should be stretching they should be using now correctly if I’m saying anything wrong because this is your episode you’re the expert I’m just someone who who’s a dentist has an interest in this area but am I right in saying that you guys are encouraging more movement and not the whole “stick to soft diet don’t talk too much” that kind of stuff?

[Krina]
Completely and really as physiotherapists what we want to do is improve mobility, reduce their pain and more importantly establish normal movement and rehabilitate towards function so when it comes to the TMD really what we’re looking for is that are they eating and all foods? Are they chewing on both sides? Are they really strengthening wise? Should you only need food for your meals to strengthen the jaw, you don’t really need to do extra chewing gum or anything any extra exercises like that’s enough.

But it’s about making them aware as well what tmd is and making sure that they’re using everything that they should be using towards functional. Chewing on the warning properly or they’re avoiding certain things and so that’s exactly what we want them to do is we need to have more movement not stop doing any sort of movement.

[Jaz]
Awesome. So you touched on myofascial pain, you said that you’re using a dry needling a fair bit and the prescription of exercises is the main thing that you would do? Is there anything else that we should know about the treatment that you provide for myofascial patients?

[Krina]
Yeah so there’s I think in literature when they talk about physiotherapy they obviously talk about the exercises but there’s also something called manual therapy which is where we are mobilizing a joint you can do all joints and so it’s not like chiropractic treatment where you’re cracking anything. This is making joint movements within your normal range of movement, okay?

So at the tmj joint we will do a distraction technique I put some gloves on thumb inside your mouth and then distract the joints I think it’s only a couple of millimeters which is what i’m showing there but basically this is the direction you’re going and what that does is that it gaps the joint so you can increase blood flow into that area but in terms of myofascial pain it then allows us to stretch the temporalis and the masseter as well and then we do a lateral movement as well still internally and that allows us to work on the pterygoids and possibly the disc as well.

So that also helps stretch that muscle so that the trigger points don’t happen as often alongside the exercises because otherwise all you’re doing is loosening something, someone off and then what once they stop seeing you it’s all going to come back again. So the strengthening part and then being compliant with these strengthening exercises is really important.

[Jaz]
I often liken what you guys do a little bit to how we as dentists treat perio disease. So what we do the deep cleanings that we do at the practice is important to remove the biofilm but what they do at home thereafter in terms of their maintenance, their tp brushes is what really does the treatment so same you guys do your manipulations or sort of joint manipulations and you but you prescribe the exercises for them to continue at home and that’s what’s strengthening everything is that is that a fair analogy?

[Krina]
It is and you have to make it easy for the patient. I’m sure you guys do as well. There are a couple of take-home messages really so I’ve done a video of me doing the exercises. So that they’ve basically got no excuse to not do them and also they’re compliant and there’s no way that they’re doing something else because you tell them one thing and then they come back saying yeah I’ve been doing it and actually they’re doing something completely different. So I have videos and I explain like I spend about 45 minutes with them for a session because I really want them to understand their own condition how they are responsible for it as well, not just moving in hands-on work and I think I’m still working on it I think I can I’m able to get that message across.

[Jaz]
Awesome. Perfect. Next thing I want to ask is a very clinical question in terms of dentists. We see patients who have their mouth open for long periods of time let’s say we’re doing a root canal treatment or a difficult extraction and obviously the muscle is responsible for mouth opening primarily there’s others as well but primarily we’ve got the lateral pterygoids and that contracts the lateral core, it shortens the muscle, it can go into spasm.

Now it has happened and I know you’ve seen these patients as well where the dentist has said okay we’re done with the procedure you can now close and then suddenly they’re in masses of pain and what’s happened is that the disc has acutely displaced anteriorly and now what they have is an usually it would be a closed lock where it can actually mean I’m trying it can be an open lock as well because the disc has gone posterior, you tell us what you see more of but how can we prevent it? I’ve sort of given a few hints then decide how we can prevent it and what I think but I want to hear from you but also how do you treat that and see if we don’t have a physio near us, how can we treat it? Just acutely the acute management of that really painful situation?

[Krina]
Okay. So you’re right it’s basically the lateral pterygoid that’s gone into super duper spasm. So when I say if I was treating that patient, if I got that referral then things are-

[Jaz]
Ideally you wanna see them fresh right? You wanna see them the same day right? Imagine or my-

[Krina]
As soon as possible but same day would be great because then that way I can really bring the inflammation down that’s and bring the spasm down quicker otherwise it’s just going to get more and more tighter as I ideally gets the first day but then I would do I have a laser a low level laser, that i use which works on pain and inflammation.

So i would do that around the actual jaw joint and I always take it down into the masseter because those muscles starts going into spasm as well after a while and usually with these patients who end up with these acute marks they probably already had underlying tmd symptoms before but it wasn’t recognized maybe the dentist never realized before they did and they didn’t think it was that bad. Sometimes patients have no idea that they even have a click or a part or they grind or clench.

[Jaz]
Krina, I just add one thing for dentists out there that we all have these, Krina. We have these patients, we hate them right and it’s this kind of patient who you say open and within about six seconds just usually a six second mark they start closing again and they say open again and they keep closing okay? These are the patients these are one risk factor that you can see that hey why does this patient keep closing they’re obviously struggling in a muscular state to keep open so these are patients that will really benefit from using a mouth prop to take that load away from the lateral pterygoid but yeah that’s one type of patient that we should be looking out for that ‘hey this patient could be at risk of this happening after a long procedure’.

[Krina]
Exactly. So yeah so and then I would do the mobilizations again so because of the mobilization I said with the destruction technique I’m able to gap the joint that then allows if the disk is displaced anteriorly allows the disc to possibly come back as well but then because of the lateral movement I do I end up stretching the pterygoid as well so if i’m able to gain the length in the pterygoid then the disc can also come back onto the condyle as well and then I will give them some-

[Jaz]
Is that painful, Krina? I can imagine them really being a lot of pain when you’re distracting or not?

[Krina]
No. It’s not. You just feel stretchy at that stage I’m not I could really go for it but I don’t, I make sure that it’s all within their comfort levels and just because I don’t want to increase more information there cause there’s already information that so you don’t want to do that and there’s a lot of TLC involved with that stage if it persists then yes I do then a little bit more aggressive with the mobilization side but initially no it’s not painful and within the first couple of sessions you’re able to resolve that anyway and you never really need to get to a point where it’s persistent.

So if I’ve seen someone a few months down the road and actually there’s a lot of adhesions in there but yeah no it’s resolvable. And then once it has resolved i will then reassess them to see do you actually have tmd associated symptoms free dental procedure and usually like a hundred percent they do and they just don’t know. So then I say you know do you want to address this and usually they do because they like you say they struggle with opening. But then there’s the opposite patient who can open so wide and can stay open and then those are also patients that probably a physio needs to see because you know they’ve got like 50, 55, 60 millimeters of opening.

[Jaz]
Hypermobile.

[Krina]
Hypermobile yes and they’re moving around everywhere the sense of throat hinging and rotation doesn’t really exist with them. So those are also the patients that probably need to see because they need strengthening and because their ligaments are so lacks the muscles have to compensate so just a little bit of strengthening work will just allow them to stop subluxing as much-

[Jaz]
And that patient I described comes in an acute scenario and you see them. Is it typically an open lock, i.e. their mouth is open or is it a closed lock and they cannot open? Which one do you see more of or is one more common than the other?

[Krina]
Closed is more common from what I see by far yeah. Closed is more common where that is designed to really displaced. It’s very, it’s red, I’ve seen an open bite.

[Jaz]
Yeah that was my understanding as well I thought close is more common because the disc is stuck in front of the condyle and you can’t open beyond that 15, 20 millimeter is on one side so I imagine in that situation you see a lot of them where it’s happened on just one side unilateral and the jaw is deviated one side?

[Krina]
Yes. Exactly, so when they’re opening it’s a straight line deviation it’s not the s shape, it’s a straight line deviation to the same side because the lateral pterygoid has pulled them over onto that side and then you when you see them basically centralized as the lateral pterygoid relaxes.


[Jaz]
And in terms of prevention do you think it’s fair as a dentist to recommend using a mouth prop, firstly identifying who may be at risk? B) using a mouth prop and C) you know referring to using our physios even before you get to those long appointments to help strengthen things to help the patients heal and function better and hopefully if they have headaches and stuff that you guys can help them right? With headaches?

[Krina]
Right and because I get this question a lot from dentists like how I should be as a dentist assessing the patient quickly. So and then I know whether they are attracted should i be taking other things into consideration should I even be referring to you and i usually basically tell them is that it’s not really you don’t have to do loads of things really maybe, when the patient comes in or before their appointment you can send there’s this questionnaire that physios use where there are objective markers as a baseline of and we’re checking their oral habits, we’re checking any limitations in this call. There’s a question there called the draw limitation scale and maybe sending the moves out to patients whilst they’re sitting in the reception getting them to fill that out and it also then checks their psychological state as well and then assessing them from both of those points.

I think it then allows you to see do they actually have a tmd condition and are they in a high psychological state right now as well and then you can think well actually maybe i do need extra information, maybe I need to put this prep in maybe I need to send them for physio but maybe sending those questionnaires up might help and the dentists that do use it they have found it useful because otherwise then if they end up with an acute afterwards that’s more trickier to deal with whereas just giving them the questionnaire and then putting the block in and sometimes the patient just needs, they need acknowledgement that this is being taken into consideration as well especially if they’re perceiving a lot.

[Jaz]
Are these available okay like can I share these with the little community listeners, the Protruserati. So if you could send those to me I’ll put them on the Protrusive Dental community facebook group and then link it back to this episode so then those people can listen in and learn more. Would that be okay?

[Krina]
Yeah and I think maybe the other thing as well is there’s like the myofascial pain chart as well so I think if dentists just learned where a few of the trigger points were and if they found that actually they were active so not just palpating actually on the joint but palpating maybe some of the neck muscles as well that might also help you to reach the diagnosis of actually maybe then really those are the kind of patients I should be seeing as well or any physiology you should be seeing as well and especially if their symptoms don’t resolve and after all of those things then. [inaudible]

[Jaz]
Brilliant. Have you found, just a few excessive questions they want to ask you, have you found that the most complex patients are those chronic pain patients that have also got fibromyalgia and all the other things going on multiple systems and your line of work I mean it’s difficult like any medical practitioner any physio any dentist we can’t always give 100 percent guarantee. We can try our best but in those most difficult patients, what percentage of success can you get on those do you think? You may not be able to promise complete resolution but you might be saying look we’re hoping for an improvement in your very complex case give us a flavor of that.

[Krina]
So when I get referred a patient like that in my assessment process there’s a lot of talking, it’s a conversation it’s not just me telling them what’s actually going on in that I will tell them that because they have fibromyalgia ibs it’s been going on for 10 years for example and it’s difficult to say what the actual success rate is going to be and I’ll list out let’s say the OPPERA study and just my own experience as well is that because it’s so multifactorial. All I’m actually doing is working on the joint and the surrounding muscles now if that is if that is 100% the reason why they are in pain or whatever their presenting symptoms are then I’m quite confident that I will be able to resolve their symptoms but if they’ve got a person at home that drives them crazy and they’re adding to their stress and that’s 50% of the reason why they’re in this situation then I can do nothing about that and so i’ll try and explain it to them like that and that it’s so multifactorial and there’s a lot of sales management involved and so I mean success rate varies. It just depends.

[Jaz]
Oh no I love what you share. I love the way you put it. If these areas are 100% contributing to your pain. So I say the same thing for my splint patients because as a dentist I cannot treat headaches and I don’t treat headaches okay? So as a dentist I don’t know for the record any dentist we do not, we cannot treat headaches, we cannot diagnose headaches be careful. However I will take a headache history and i will say look what I’m treating here is prevention of your parafunction, prevention of your grinding damaging more teeth and some of my patients have found that if that was the the trigger that was causing the muscles into overdrive that was then also contributing to your headaches and that’s the percentage of success we’re going to get with your headaches and I love that what you said because it’s very similar to how I say as well but I think there’s a definitely a role in there for you because i think my most difficult patients who have found some success with splints I think you raise a great point that they’re not wearing the splints during the day and I think that’s where really you guys come in to re-strengthen and to stretch and relax everything, that’s everything and i think there’s a whole adjunctive therapy alongside the splints that we provide and i think it’s a huge role that you guys have.

[Krina]
Yeah and I don’t think it’s either. So it’s not like you see a dentist or you see a physio ideally and in my training all allied health professionals, we are trained to work as a multi-disciplinary team. So when I entered the world of tmd and specializing in it, it was just surprising of how one multidisciplinary it is like everyone’s doing their own thing and actually I think that if we all just grouped together and said okay well you’re great at this, you’re great at this and so when I see a patient who has but you’re great at that I can send them to you.

So what I really really want to do is create awareness on what I’m doing. I want to know what other people are doing, I’d love for people to get in contact with me and say “oh you know this is how I can help you and this is how I can help them with that” and just creating awareness that this exists because sometimes splits aren’t working or sometimes nor tip totally and elaborately isn’t working for them or maybe they just don’t want to do it they’re not complying with those sort of treatments then there are other things out there and I think if we were able to get in contact without the threat really and then it’s only to the benefit of the patient really.

[Jaz]
I completely echo what you’re saying because I think we do need to work more as a team and I think many of the dentists listening to this today they’ll probably be like if it wasn’t for the earlier tip I’d given as a pearl to check out ACPTMD they’d be like what there’s physios who do who do tmj? What? I mean these dentists probably don’t even know you guys exist so that’s the point of getting you on today so we can discuss this kind of stuff and it’s been it’s really great talking to you about this I think I’ve covered the main questions but I just wanted to give you a quick fire question according to what you believe can you palpate the lateral pterygoid or not?

[Krina]
I, personally, so there’s a lot of controversy on this. I personally think that you cannot because so we were taught that you put your index finger through up to the zygomatic arch and then you go cranial and then that is basically the lateral head. So then you do that okay then at the university of louisville when I did the master’s module we had divers and they when we actually lifted all the flats and tried to find where the lateral torque was actually we were touching the medial pterygoid so I just thought what there’s I don’t know whether I’m on the lateral or the needle here in a patient um so I concluded that you can’t some people believe they can-

[Jaz]
Yep same here I agree with you and um although I haven’t I mean I’ve worked with cadavers before as a first year dental student but back then I didn’t know what tmj was so I wasn’t even looking for the- I don’t know what lateral pterygoid was back then. So now that I’ve read the studies where they’ve done worked on cadavers to see hey through a cadaver while we can see, can we palpate using the technique that we use in the chair can we palpate the lateral pterygoid and these studies have shown that no you know we just can’t do it you can’t predictably do it at all and you know the pain sort of perception that people when you do this test suppose a test for that lateral pterygoid there’s a hundred percent chance to a patient going ah that really hurts okay so it’s not a great test but for that reason as well so what I do is I test for that pterygoid by against against resistance yeah for my hand so those listening put my hand under the chin get them to open up against resistance and that’s obviously putting load if you like or give providing resistance to the lateral pterygoid, is that how you would do it as well?

[Krina]
That’s exactly how I would do it and then I would then safely say that actually there is tightness up there natural thyroid or displaying that depending on what and then also measurements from you know lateral excursion and seeing if the discrepancy there that also adds to the picture of what’s going on and then deviations s-shapes that sort of thing so that then all just adds if you don’t have to just palpate to then say the lateral there’s other ways as well.

[Jaz]
Absolutely and but there are some eminent physios who would say that no I can’t feel the electrical work this is definitely pterygoid so this is the beauty I always used to look at this kind of difference that ‘ah this is terrible why can’t we all disagree but this is the beauty of dentistry. Now there’s the beauty of physio that there are different opinions. I’m sure there’s different schools of thoughts within. I’m sure what you do there might be some physios thinking ‘oh that’s very controversial or whatnot and I’m sure you see other physios doing that hang on a minute, that’s not right and it is the way it is this is how our professions work.

So it is brilliant you’ve answered all my main questions. Now I want to give the mic to you to just any advice you want to give to dentists getting into this field and B) How can we follow you on social media? Give us your social media handles so we can learn more from you.

[Krina]
So maybe advice to dentists would be is that so as physio hopefully through this podcast I’ve actually highlighted that we don’t just massage the masseters and now we actually have a different range of treatments that we’re actually able to do and things, we’re able to treat as well but also I think if you’re able to get the muscle chart maybe I can send it to you and people can download it and I decided a muscle chart to actually look for the myofascial pain because that’s probably 70% of the patients that most people treat with tmd and then I guess people can find me on my website which is krinapanchalphysio.com and I’m also on instagram where i’m probably the most active @krinapanchal and can see lots of patient videos interviews that i’m doing with lots of maxillofacial surgeons I’m working with at the moment as well and just showcasing how this can actually be treated.

[Jaz]
Amazing. We definitely. I’ll put the handles on that and the website and any downloads that you do email me over please remember, Krina, so I can add those on and I just thought the story actually the first time about two and a half years ago I actually referred a patient to a physio, tmj physio.

Found him through the ACPTMD this is when i was working in oxford and I was amazed I had this patient who had this acute episode where he ate something hard and he felt a crunch and now he’s a bit of pain but now he cannot open and his opening was about 35 millimeters and I was like wow I don’t know maybe I should send you a physio and then when one session and one treatment he was able to get him to 51 millimeters I was like wow that’s amazing that really opened my eyes you know all those years ago I suppose but you guys as we covered today see so much more than that and I think you guys are a really important part of the team in managing “TMD” which is a massive umbrella term but I urge you all to find a physio near you that you can refer to. You’ll get so much more success, success with your splint.

So I’ve got the splint course coming out very soon and I’ll be adding a whole bit on that you know make an alliance with your physios, they will help you and for your toughest cases you need them because chronic pain is tough. Your splint will not help chronic pain that’s why I try to stay away from it. I like to cherry-pick the easier cases. It’s so much your success rate should be so much higher that way but Krina, thank you so much for coming on and sharing your time and expertise with us today.

[Krina]
Thank you so much for having me, it’s been a pleasure.

Jaz’s Outro:
Guys thank you so much for listening all the way to the end. I really appreciate it as always. If you’re listening to this and it’s like this is a brand new episode then wow I have just pretty much launched my splint course or it’s about to launch so on friday I’m launching the splint course. splintcourse.com I’m so so proud of it. This is my baby. It’s taken so many years of video recording, late nights, early mornings to finally bring this 10 or 11 hour course into fruition.

I say 10 or 11 because it depends on whether you count the bonus modules or not so I’ve got lots of content on there I won’t bore you because i’ve already told you all about the splint course already and various opportunities so please do check it out if you’re interested in learning more about occlusal appliances check out splintcourse.com. Krina was one of my beta testers because I was really keen to hear her opinion of what she thought I was teaching dentists because I wanted to have a whole section on there, on the importance of conservative care and the importance of physiotherapy.

So check out the splint course if you haven’t already and I look forward to seeing you there. Otherwise I’ll see you in the next episode and hey if you found this useful do follow us on @protrusivedental and also follow Krina Panchal as well her instagram handle is @karinapanchal. Thank you again everyone and I’ll catch you next episode.