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FOR PREVENTION OF JAW JOINT AND MUSCLE SPRAIN/STRAIN INJURIES DURING DENTAL TREATMENT
Trauma during dental care may occur after local anesthetic injections, hyperextension from opening the mouth too wide or for too long a period or placing excessive force on the jaw during a dental procedure. The S.A.F.E. Protocol is a pre-treatment protocol to help dental professionals prevent and minimize JAMSS injuries that can result from dental treatment. We invite you to download and use this protocol for training your staff on steps for risk assessment and patient communication.
S - Set up for Safety
A - Assess Risk Associated with Patient and Procedure
F- Follow Protective Measures
E - Evaluate the Patient Post-Procedure
The following animation was prepared by BiteFX to show the etiology of Jaw and Muscle Sprain/Strain (JAMSS) that sometimes can occur from a longer dental procedure, or for a patient who has a limited range of motion as an existing condition. As with other joints in the body, there are 4 grades of joint mobility:
1. Normal resting range of motion (teeth apart, tongue up)
2. Normal active range of motion (25 to 45 mm)
3. Maximum voluntary range of motion (45 to 60 mm)
4. Maximum involuntary range of motion (by application of a bite block, your hand or tool resting on the mandible.)
While the jaw joint and musculature are highly adaptable, in some instances the muscles become hyperactive and are in conflict when the lateral pterygoid is required to hold the jaw open on a sustained basis. This video demonstrates what can happen in cases of delayed onset of JAMSS. It is important that your staff be informed of this condition and encourage patients to call your office immediately if this occurs, rather than wait and go to Urgent Care.
A) Educate your team about the risk of Jaw Joint and Muscle Sprain/Strain (JAMSS) injuries. Make sure everyone in your office, from the person answering the phone, who might take the post-op call, to your clinical staff of hygienists and assistants, need to know what JAMSS is and why speed-to-treat is important to prevent JAMSS injuries from progressing to a chronic pain condition. Demonstrate how you will screen for risk on a pre- and post-op basis, and how acute JAMSS should be treated using the JAMSS Protocol.
B) Create patient education information on JAMSS to include in your digital signage, patient education materials in your waiting room, informed consent, and post-op instructions. Patients understand sprain/strain conditions for other joints and will relate to this concept as distinguished from other more chronic or complex orofacial conditions.
C) Educate the patient prior to the procedure so that any post-op symptoms are not ignored and are identified and responded to promptly. Patient education about JAMSS should become a part of all pre-op and post-op patient instructions.
A) Complete the JAMSS Risk Assessment Questionnaire prior to the scheduled dental procedure. Signs and symptoms indicated in the JAMSS Risk Assessment Questionnaire can help identify a patient predisposed to jaw strain, delayed recovery, or chronic pain. Document any “yes” answers and specific information that will help with treatment planning or follow-up care.
B) Perform an initial patient examination to check for acute JAMSS symptoms. The examination to diagnose and assess JAMSS risk should take no longer than 2-3 minutes and includes the following:
• Range of motion (document pre-op and post-op)
• Joint sounds
• Signs of bruxism
• Joint and muscle tenderness
C) Consult the S.A.F.E. Protocol – Dental Procedure Risk Assessment Table which delineates the severity of risk for trauma or acute JAMSS injury from common dental procedures. Determine if the procedure to be performed is Low, Medium or High risk. This understanding can be used in treatment planning, informed consent, staff training, and patient education.
D) If you identify a specific risk for JAMSS such as limited range of motion or prior history during your assessment, it is recommended that you fit the patient with a QuickSplint interim oral appliance for overnight wear and schedule a follow-up appointment in 2-4 weeks for an Extensive Evaluation. Use either the JAMSS Speed-to-Treat Protocol, or the Parafunction Risk Rating Protocol to help alleviate symptoms and gain diagnostic insight. The follow-up appointment should be documented and billed under D0160, as an Extensive Evaluation.
The extent to which protective measures are followed should be customized according to the reasons for which the patient is in a specific risk category. For example, the use of certain dental technologies, materials and techniques may result in longer treatment times and the need for staged treatment. The more comprehensive the restoration plan, the more likely the patient could experience some level of JAMSS due to frequency of care. Special consideration must be made for appointment lengths and the frequency of breaks for jaw relaxation.
For high risk patients and/or special needs patients, the following measures can be implemented on the day of a dental procedure to decrease the risk of JAMSS injury:
1. Schedule intentional time for breaks during the procedure
2. Avoid opening the patient’s mouth too wide or for too long a period
3. Minimize fulcrum pressure during operative work
4. Never force the jaw open
5. Limit the use of bite blocks that keep the mouth open for longer periods of time
6. Make a QuickSplint before the procedure for use by the patient during breaks
7. Avoid multiple injections to achieve anesthesia. If multiple injections are used, the use of the JAMSS Protocol (providing a QuickSplint post-operatively) could be used to prevent trismus and acute strain.
After the appointment, it is helpful to call and ask the patient if they have any pain in the jaw, temples, or joint, documenting symptoms that might indicate the presence of JAMSS. Schedule a follow-up appointment and conduct a post-treatment assessment for Medium and High-Risk patients using the same patient evaluation steps described previously.
Post discharge Evaluation:
A) Complete the JAMSS Risk Assessment Questionnaire
B) Perform a patient examination to check for acute JAMSS symptoms. The examination should take no longer than 2-3 minutes and include the following:
• Range of motion (compare to pre-op measures)
• Joint sounds
• Signs of bruxism
• Joint and muscle tenderness
There are two situations where you should consider implementing the JAMSS Speed-to-Treat Protocol:
1. If the patient presents with pain and/or tenderness in the muscles or joints and/or limited range of motion (a decrease from the pre-treatment ROM measurement).
2. If the patient has a prior history of complications, or showed signs of jaw fatigue during surgery.
This document outlines the S.A.F.E. Protocol and can be used for staff training. We can provide PowerPoint slides for Study Groups and Educational purposes by contacting us at info@QuickSplint.com
Download this table and review with your front desk, dental assistant and treatment coordinator. This table is designed to help you identify a higher-risk procedure that may present difficulty for a patient who has trouble keeping their jaw open too long, or too wide. Your staff may want to schedule time for breaks for the patient’s jaw, or to be prepared to offer a QuickSplint post-procedure to ensure that the patient’s jaw joint and muscles will relax and heal.
Use this questionnaire to evaluate patients for risk factors associated with Jaw Joint and Muscle Sprain/Strain. If the patient has a prior history or has other risk factors, follow the S.A.F.E. Protocol to manage higher risk patients and procedures using prescribed injury prevention measures. It is best to use this questionnaire at the time your office is scheduling a major procedure.
Heat, Exercises, Analgesics, Lifestyle, Strain
Because Jaw and Muscle Sprain/Strain can sometimes take two to four weeks to return to normal function, this handout is designed to provide patient self-care training on managing pain, daily jaw care and how to avoid risk factors for delayed recovery.
This handout can be used with or without QuickSplint (the patient may not need a QuickSplint post-operatively, but your staff can encourage the patient to call if their symptoms are not improving.)
This flyer is designed for display in your waiting area, or as a handout you can offer when you discharge the patient after a long dental procedure.
The objective is to encourage a patient to contact your office when they are symptomatic so that any jaw and muscle sprain/strain condition can be addressed quickly with QuickSplint. Patients understand sprain/strain conditions for other joints and will relate to this concept as distinguished from other more chronic or complex orofacial conditions.
Jaw Rx-Ercises are a set of jaw exercises designed to help patients avoid daytime clenching (muscle guarding) or setting of teeth that causes jaw and temple muscles to overwork and become sore. For patients with acute JAMSS, daytime exercises maintain blood flow to the muscles and joints to improve range of motion over time.
Masseter or jaw muscle soreness can be a trigger for headaches and/or jaw pain. Performing Jaw Rx-Ercises throughout the day for up to one week will retrain the jaw muscles and brain to relax the jaw in a comfortable resting position, keeping teeth apart and tongue up.
TAKE A CE COURSE ONLINE
Earn 2 CE units of peer-reviewed continuing education via the online course, Postoperative Jaw and Muscle Pain, A guide to risk assessment, prevention, and treatment by Lee Ann Brady, DMD; James Fricton, DDS, MS; and Brad Eli, DMD, MS
Cost is $16 - Learn More
FDA 510k- CLEARED AND CE APPROVED FOR SHORT TERM TREATMENT OF TMD PAIN AND ASSOCIATED HEADACHE AND BRUXISM PATIENTS OR FOR PROTECTION OF DENTAL RESTORATIONS.
© 2018 Orofacial Therapeutics,LP. QuickSplint® is a registered trademark of Orofacial Therapeutics, LP. Speed-to-Treat® is a trademark of Orofacial Therapeutics, LP. All rights reserved.