Good evening, everybody. I would like to take the first few minutes here to share some current evidence that's known in the field of temperament-individual disorders, and then as we continue on with the conversation here, I look forward to be able to answer some questions that might come up from an evidence-based foundation. The terminology of temperament-individual disorder, it's been evolving over the several years here. I would say 60 years almost now in terms of the evolution of it, but overall, though, the most recent reassurance we have or understanding we have is documented well in a consensus report. The report emerges out of a committee that worked towards developing this and published by the National Academy Press in March of 2020, and the report basically defines TMD, or temperament-individual disorders, as a set of diseases or disorders that are related to alterations in structure, function, or physiology of the masticatory system that may be associated with other systemic and comorbid medical conditions. So it's a broad term that captures groups of disorders. On the one hand, we have the common TMDs with their validated diagnostic criteria, popularly known as the research diagnostic criteria, RDC, but then more recently, DC-TMD, and the uncommon TMDs that do not yet have validated diagnostic criteria, mainly because conducting research to validating those diagnoses are difficult because of rare conditions there. It's impossible. A patient's diagnosis needs to be focused on a specific TMD because, ultimately, when we render a diagnosis of temperament-individual disorders, it is going to be one of the diagnostic terms. It's going to be… We don't diagnose somebody with TMD, we diagnose them with TMG arthralgia, myalgia, and so on and so forth. So this is the broadest form of meaning that TMD as a term can take today, and I would highly encourage everybody to explore this. This report is accessible with the National Academy of Press, and it's downloadable as a PDF form, and it's a good overview of current status of evidence in various aspects of TMD. Some of the common temperament-individual disorder diagnoses, it's kind of trying to make a point with the list here, which is exhaustive, but the bottom line is this taxonomic classification of temperament-individual disorders was published as a part of the Diagnostic Criterion TMD, DCTMD, abbreviated, by Eric Schiffman and group in the Journal of Orophageal Pain in 2015. But since then, it has been the standard for the vast majority of research publications identifying temperament-individual disorders in the clinical environment. Broadly speaking, temperament-individual disorders, the most common, the common TMDs would be temperament-individual joint arthralgia, which is the specific criterion for diagnosing that is outlined as an appendix to this particular paper. We have joint pain, duplication of joint pain with palpation, masticatory muscle myalgia, myofascial pain, temperament-individual joint disc displacement disorders, where there is disc displacement with reduction and without reduction. There's degenerative joint disease, the temperament-individual joint, temperament-individual joint subluxations and headaches attributed to TMD. These are the most common types of TMD diagnoses that could be formally arrived at using the DCTMD. When we look at diagnosing TMD and the role of occlusion in it, what do we know from research? What evidence do we have? Well, back in the 1960s, the foundational ideas were housed in this paper that came out of Dr. Bramford's work, and essentially the research was done with 32 patients, well, the publication documented 32 patients with occlusal interferences identified and adjusted to manage their TMD pain. However, there was no control group, and this was later postulated by many researchers to say, well, it's not causal, you intervene for that particular identified abnormality, and therefore a causal association was negated from that paper. But beyond that, multiple publications have documented very clearly this particular one by Terp and Schindler back in 2012, looked at the epidemiology, the prevalence data of occlusal interferences, occlusal disorders, and its association with TMD, and there was very limited statistical or clinical evidence for a causal association. Sure, certain occlusal patterns were more prevalent in patients with temperamentably joint disorders, but they couldn't be deduced a causal association, and it's 60 years since, and we really still do not have a causal association for an occlusal disorder to cause temperamentably joint disorders. When we look at prevalence, okay, how prevalent is temperamentably joint disorder, and there's a lot of data there, but if we focus on the environment where we are in, treating obstructive sleep apnea with oral appliance therapy, what is the prevalence of TMD in the patients who walk into that environment? Well, it ranges between 19.8%, as documented by Perez in 2013, or Kinali to up to 52%. Bottom line is, patients walking into a clinical environment seeking oral appliance therapy could have a preexisting established temperamentably joint disorder, which needs to be formally identified at that point, and Perez et al. went further and said, after the oral appliance therapy, these preexisting TMD conditions did not show any exacerbation, so it becomes important to identify these independently as a concurrent condition, orally using the DCTMD criterion, so that oral appliance therapy triggered disorders can be separately identified for what they are. So this is what I want to frame it as with evidence. We know that a good percentage of our patient population seeking oral appliance therapy may have a form of temperamentably joint disorder that needs to be identified and managed. What can we use to identify? What evidence do we have in literature to identify these disorders? This is a component of the DCTMD publication. There is a screening instrument for painful temperamentably joint disorders. This questionnaire has a short version, question 1 through 3A is the short version, and the entire questionnaire, question 1 through 3D, becomes a tool or an instrument that we can use in a clinical environment. The excellent part about this questionnaire is that, one, it is very well documented in research for content validity. The sensitivity in terms of picking up a painful temperamentably joint disorder is up of 99%, meaning they're very, very low false positives, and then specificity, identifying a specific type or correct classification of TMD, particularly painful TMD, is also very high. Also, there's very good specificity for non-painful types of TMD with this questionnaire. So it's a great starting point. It's a well-laid out clinical tool that can be taken home to our practices just from what's been published. This is something that I, by the way, I use this in the clinical environment all the time. What do we know about, now that we've screened using the TMD screener, use the diagnostic criterion from the DCTMD to identify the type of temperamentably joint disorder this patient could be having? What treatments are available for that? Well, what evidence tells us? This is a fantastic paper, again, something that is seminal, considered to be in terms of treatment strategies for TMD, published in the International Journal of Oral and Maxillofacial Surgery recently. This is a, there are two papers here, this 2007 was the first publication tied to the same data, and then 2014 now, most recently, 90 patients with MRI confirmed recent onset TMJ closed locking, meaning this is a disc disorder where their jaw joint, the disc is non-reducing, meaning they have limited mouth opening, they're feeling locked, painful. These 90 patients were randomized between four treatment norms. And one group received medical management, which was a combination of prednisone for the first six days, and then up to six weeks of anti-inflammatory therapy, non-steroidal, ibuprofen, moscofin, and then potentially up to 10 days of cyclobenzaprine, 10 milligrams at bedtime. So that was a medical management group, approximately 20 to 25 patients received that. Another group received the non-surgical rehabilitation, which was a combination of medical management plus a flat-plane occlusal splint and physical therapy exercises and self-care strategies. By the way, the medical management group also received some home care, self-care strategies. And then the third arm was arthroscopic surgery, and the fourth arm was arthroplasty. They did the outcome analysis in terms of pain and function at three months, six months, 12 months, 24, and 60 months. And what was really striking is that the success rate did not differ significantly between the treatment groups. Everybody got better by the same amount at all points of follow-up. And significantly enough, more than 50% of the medical management group, which received home care, education about temperamentability joint disorders, some non-steroidal anti-inflammatory, an early course of prednisone, responded positively. And just adding the rehabilitation piece was the only thing that was required as a crossover, that we found the outcomes were well enough and conservative enough that was done. So bottom line is, from a treatment approach for TMD, this gives us clarity as after the most conservative interventions work as well as some of the most invasive options for treatment. And you can see that occlusal splint is one strategy added on versus it being an independent approach alone. When we look at TMD as a side effect, so okay, we have screened for it, we have diagnosed it formally. We know what to do to treat it once we identify it. How often are we going to see this? And when it presents, how does it manifest in the oral appliance therapy population? This was a study done, very well done study by Doff, looking, it's a parallel randomized control trial and had two groups, 51 patients received oral appliance therapy, 52 of them received path therapy. And both groups were observed for nuance occurrence of TMD symptoms. While the oral appliance therapy group showed a slightly higher occurrence of temperament of the joint disorder, TMD pain did occur, but neither group had functional limitation from the TMD pain. And even if it occurred more frequently in the oral appliance therapy group, it was temporary. And it was therefore concluded upon the finding that temporary TMD symptoms may result from oral appliance therapy and therefore not really needing to be a contraindication for oral appliance therapy. Similar findings also noted, and this is a little bit more of a robust design, they had a placebo arm, 64 patients were divided into three different arms, the third arm being the placebo where they had a palatal retainer, a hard acrylic retainer, versus the other arm being oral appliance therapy and then the nasal path therapy. And they found once again, six months after initiation of treatment, no difference between groups for the occurrence of TMD symptoms. And therefore also no difference in the divider functional impairment, and once again, deemed as a temporary phenomenon in oral appliance therapy patients. So as we gather that information, we also have this convenient consensus document emerged out of ADSM that tells us that we have a strategy for transient morning jaw pain. And for persistent symptoms, we have an approach with device modifications in addition to palliative care. So we look at the palliative care, the isometric contractions, and I'll leave Dr. Conner here, Emily, to talk about that. But bottom line is, we find once again, medical management and rehabilitation with occlusal splint combination of physical therapy approaches seem to be sufficient in managing TMD, particularly in oral appliance therapy being a temporary issue. Therefore, walking through once again with our patient, we can base our entire strategy of managing treatment emergent TMD on evidence, which is fairly robust. We have a rich foundation for that. So with that, I'd like to hand it over to Dr. Vaughn there, Alex, and to help us navigate it from a clinical perspective. Wonderful, thank you very much. I'll highlight too, before I start my presentation, that I intentionally did not view Zuba's slides first to kind of create my own and then see at the back end how much they lined up. Because I always find that fun to see, do we find that the research matches the clinical? Which it should, right? I mean, I certainly don't, I'm not going to go out there and say I practice based off of non-research. But it's always good when you get multiple providers across the country kind of saying the same things. So let me start this PowerPoint here. So before we go into this, I want to add some key kind of focuses that I want to highlight whenever I talk about orophageal pain, especially, and the first one is we need to take off our dental hat. What I mean by that is as dentists, what we treat is often, let's say failures are our fault, early failures, I should say. So if the crown falls off in a week, that's probably on me, you know, I probably didn't isolate well, or I didn't have good retention or enough ferrule or whatnot. If the oral appliance doesn't fit at all at delivery, it might be my impression. You know, I mean, there's a lot of dentistry, we have such great control. And as bad as it sounds, our patients most of the time really, at the end of the day, a lot of their dental concerns are almost like treating a typhodont. And at the end of the day, when we're looking at pain and sleep, we're now moving into medicine. And so we need to take off our dental hat and take off that almost assumption of failure. So when your treatment fails in dentistry, again, we take that personally. In medicine, I don't know, of course, everyone in the audience, I mean, you have your own medical conditions, but I have a weird heart condition that took my physicians three years to figure out. And I went through countless bottles of pills trying to figure out, okay, which one is the right one? Does this do it? Do I need one of these and two of these or three of these and one of these? And that takes time. And in dentistry, we're not used to that. So taking off your dental hat is key whenever you're looking at oral facial pain. And then the second thing here is diagnosis first and treatment. And that's all of dentistry, right? I mean, of course, in all of dentistry, we're looking at diagnosis first. But in this case, it's even more so your diagnosis is going to almost always lead to the treatment. So in dentistry, we're looking at, okay, it's caries is the diagnosis, you know, caries, lesion. Okay, do we do a filling? You know, do we do a direct restoration, indirect restoration, you know, what's our answer there? Well, in pain, it's a little less of the one diagnosis has eight treatments. It's more or less a lot of times one diagnosis has a treatment path or treatment modality that you're going to go down. But caveat to that, having the correct treatment and the correct diagnosis in pain and sleep does not necessarily equal relief. So being comfortable with the fact, again, that you will fail, that's normal and expected, and be comfortable in that. Then weigh your options, what do you have, what's best for the patient and really engaging that patient. Again, when we look at dentistry, if the tooth is half gone, but we've got ferrule and a healthy pulp, we're probably going to recommend a crown, you know, I mean, there's not a ton of options in that case. In pain, there are options and melding it with the patient's life and getting them a functional result is much more important than getting them the textbook result. I run into this all the time with arthritis, for example, that is my least favorite diagnosis to give a patient is osteoarthritis, because I got nothing, I got nothing that fixes that for the most part. I have treatments that make it better and improve their life and improve their quality of life. I can't get rid of it. So, you know, we're weighing our options and improving their lives, not necessarily curing their condition. And this is where I was saying, I'm glad I didn't match my slides up with Subha, yet they match here with time, giving patients time to heal is magical. We do this all the time with oral lesions, if the patient shows up with an ulcer that we can't identify, sure, we can biopsy it, but more likely than not, we're going to say come back in two weeks. If it's there still, then we'll care. And sometimes with sleep appliances, especially time is the magic. For an example, I don't follow up with my patients after delivery by about three to four weeks. And that's intentional, because if I follow up at one week, if I call them, how's it going, they have pain. If I call them at three weeks, they're fine. And so giving your patients time to heal and regress to that mean, in other words, just naturally, you're going to have these outliers at the front end, but at three to four or five weeks, we kind of heal and letting people regress to that mean and get normal is sometimes what you need. And the last thing I'll highlight here, and this is the key for all of my slides, especially with Emily here to give us such a great perspective, is that all of my slides involve physical therapy, but I don't put it in the slide. But I want you to kind of have that in your background in your mind. Remember, the TMJ is a joint. The J stands for joint. It's not temporal magic joint. It's temporal mandibular joint. It's just a joint. It's not magical. There's no super crazy thing about this joint. Sure. We got teeth to be the end stop and most of our joints don't have end stops like that. They have ligaments that stop them. The jaw also has ligaments that stop it, right? That's vertical dimension of occlusion when we're missing teeth and we're looking at a patient that's a dentalist and why it hurts when we violate that, right? We're getting a ligamentous pain with that. But we have to remember this is just a joint. We have in dentistry so complicated this thing that we get off the rails and it's a joint. At the end of the day, it's no different than your knee or your hip or your shoulder. Treat it the same way. And as we go through these kind of that's what I want you to remember. So diagnosis again, the first step is diagnosis. So what are our pearls? Listen to your patient. The history is everything. I'll be honest and I'm not trying to brag with this, but I have diagnosed my patient 95% of the time in the first five to 10 minutes before I even touched them just by listening. And then I'm touching them feeling, okay, does it hurt here, here, here, here to simply confirm. So it's similar to what we do with endo, right? Or any other thing. Okay. If it hurts when you, you know, you drink something cold and it hurts for two seconds and screams to the roof and you go, okay, I just did a feeling last week. I probably know what's going on. Whereas if it hurts for a minute and it gets worse and worse and worse, we're going to go, okay, probably endo involved. So same kind of idea with pain. So we want to characterize it and that character, these are not hard and fast rules. I don't want you to write these down and go, okay, if they say it's dull, it must be muscle, but pain enough, often enough, let's say 52% of the time, you know, barely past a majority of the time does follow some similar things. So muscle pain is usually a dull aching, kind of just diffuse. It hurts kind of pain. Tendon and joint and ligamentous pain are very much like usually sharp stabbing. It hurts here. It's an ice pick in my ear kind of pain. And then we've got these nerve neurovascular pains that are more shooting, burning, throbbing, think migrainous pain, that just throbbing headache or this shooting pain, like when you tap a nerve, when you're giving anesthetic. So the way the patient describes the pain is going to direct you to what's going on and then keep it simple. So KISS is keep it simple, stupid, right? Like just keep it simple. It is not complex. We've all been taught that this is complex, but it's not like, listen to your patient, find out what's going on. And usually that's going to lead you to it. So what helps the pain? Ask your patient that. Does it help if you take Motrin? Yes. Then you should probably take Motrin. You know, patients know their body much better than we do. And the last thing here on these pearls is ask them, where does it hurt? Just ask them that and look at how they point. If they go, it hurts right here, right here and point at it. Okay. That's probably tooth. You know, if you moved them, you know, if you just delivered an appliance, they're pointing where it hurts. That's probably tooth pain. But if they're saying that it hurts here or it hurts kind of here, now they're pointing at their joint. You know, you point to the joint for pain. A lot of times they'll tap or kind of feel the muscle. It hurts here, here, here. Those are all regional pain. So these regional pains are not going to be tooth or joint. Um, they're going to be more muscle or, or, or, or something like that. Now on your physical exam, what are you going to look at your patient? So when we're looking at a history, we use the zero to 10 scale, your, your visual analog scale that that is don't turn feather me or facial pain community, but it's completely useless and worthless. Uh, trying to figure out a seven versus an eight is a joke. Uh, it's not possible when you're, when you're feeling your patient, you're actually touching areas. Give them a pain scale of zero through three. So zero is no pain. One is anything more than a zero. Even if it's minor, it's a one two is, Hey, that hurts. And three is if you do that again, I'll punch you. Uh, and I explained that to my patients that way they get it. And now we're going to get a better idea of mild, moderate to severe pain. If you say mild, moderate, severe patients, aren't going to get that. You're going to get moderate pains that are mild and mild pains that are severe. And you're going to get these weird confusions zero through three and explain it in simple terms that they can understand. And you're going to get much better result muscle palpation. So feel the muscles. Um, I pet peeve of mine is you, you can't palpate the lateral thyroid from intraorally. So when you feel, if you've been taught that you're, you're palpating the, the, the origin of the masseter, you're not palpating the lateral tear guard. If you're doing the palpate up the ridge, it's just not there. That's not where it inserts or originates. So it, but, but having said that feel for the muscles, if you get a top band, a knot, if you will, in the muscle, think, Hey, maybe that's a myofascial pain or trigger point push harder. Does that replicate the patient's pain? If I push here and it hurts here, I have a pretty good idea that that's myofascial, um, palpate the joint and have them open and close, feel the joint. Does it hurt when I push on the joint? Often your patients will take your hand. No, no, it hurts here. That's fine. Tell him you're just feeling to look for normal. Um, and then ligament palpation is a little harder. The one I like is, is actually a tendon. So I apologize for don't, don't kill me, Emily for, for messing up ligament and tendon, but the temporalis tendon, I do like to palpate right up the coronoid process. So just run your hand right up the coronoid process. If they punch you, it's the temporalis tendon. And that's most often what it is. Uh, when you've got a patient that's eight, nine, 10 out of pain, sharp stabbing shooting, Oh, this hurts right here. Check the temporalis tendon. It's usually that, um, last couple of slides here really quickly. Uh, muscles are toddlers. Think of them that way. They are quick to be angry and quick to get better. Um, they make no sense. They will love you five seconds later. They'll hate you. That is a muscle. Um, a lot of times, just like toddlers, you just need to give them a time out, like just put them away, tell them to calm down. That's what we're doing with a splint. That's what we're doing with medications, like just chill. And when you do that, the muscles calm down and they get used to normal. Um, they don't like change again, they're toddlers. Um, but let your patient drive. If they say, Hey, it's minor. It doesn't really bother me. Let them live with it. A lot of times they'll improve. Um, when we start intervening is when we start sometimes coaching and teaching the patient, this hurts. Um, as far as your appliance, do you back it back or do you pull it forward? Sometimes it's, it's literally just the physics of where your appliances is messing with the muscle. And sometimes you'd pull it forward a millimeter and they're chill and it gets better. Um, so, so consider both and then muscle relaxers, pet peeve, another pet peeve of mine is nighttime muscle relaxer. Only the muscle hurts all day. I promise you most of the time, your patient is not saying it hurts at two in the morning. They're complaining about it hurting at nine in the morning or 10 in the morning or two in the afternoon. So why are we only medicating at night? Uh, why? Cause a side effect. So consider a med with less side effects. So Baclofen for example, Baclofen five to 10 milligrams, three times a day is great. A very low side effect profile, minor relief of muscle pain, but it lets them get through the day much better than just knocking them out at night when they're already asleep and the muscles are paralyzed. So the daytime use of muscle relaxers is key. Joint. If you're poking the joint, that's what hurts. Anti-inflammatories at the end of the day, it's usually inflammatory. That's the condition. Local anti-inflammatories is going to be the best answer, which is an injection of corticosteroid, um, side effects with that risk. If you don't want to do a joint injection, certainly learn, um, go through some courses on it, but you're going to have the least side effects with local topical, topical, uh, Diclofenac or Voltaren gel, which just went over the counter is great. It works very, very well. This joint is very close to the surface. Tell your patients if they say, well, I've done that before on my hip and it didn't help tell them it's a very different joint. It's closer to the surface. It'll work better. And then you go to systemic. So the, the, the, the ibuprofen or the, the Nibbuton or, or, or whatever you want during the day. Temperature works great everywhere. It works very well with inflammation, heat and cold, do the same thing through two different pathways. So ask your patient, do one, wait two days, do the other, whichever one works better, do it. Um, heat as hot as you can get cold, as cold as you can get. Um, it very simple and then move the joint, keep it moving. So this idea of rest, ice, compression, elevation, that's for an injury. This is not an injury. We want it moving. Meat is the analogy. I don't ever remember what it stands for. Um, but the big idea is move it. You want to keep the joint moving pain controlled to, to let you move it. Um, temperature to again, help with that pain control, but move that joint. And then again, consider pathology on this one. Maybe there is some joint, uh, pathology going on at a growth or, uh, an attack. You could have rheumatoid arthritis, osteoarthritis, idiopathic condyle resorption. These are where your images are key. And then the last slide here is, is ligament and tendon. Um, so if it seems more ligamentous or tenderness, the idea here is, is chill it out. Don't overexert it. Don't pull it more. It's already angry at you. Give it time. These, these, these tissues do not get good oxygen. They don't heal well. So just remember, these are going to heal slower. Um, you're not going to get a quick immediate response to meds. Tell your patients, especially if you're feeling that temporalis tendon, and it's poking at you and it's angry one to three months is what I tell my patients. I mean, it takes time and it's okay. It's going to get better. We're going to get you through it. It's just going to take time. Um, and explain that to them. You're using the NSAIDs, the non-steroidals, your ibuprofen, your excedrins to, or actually not excedrins, your Aleve to, to, to calm it down and get their pain level normal. They'll be fine. It's a two to three month crutch. They'll get over it. Um, just let them know that and they should get better. Um, so now I, I want to pass it along to Emily. She can yell at me, correct me, agree with me, whatever she wants to do. I'm happy with, uh, cause let's be honest. She's the expert on, on a lot of these things. So, uh, let me pass that off to Emily here. Thank you, Alex. Actually, I was just going to say, I appreciate your toddler analogy because I tell my patients all the time that retraining habits, like stopping clenching is like potty training a toddler because you can tell yourself all day long what you're supposed to do, but it's that exact same process as learning that new motor pattern. So, so thank you. Okay. I know a lot of what we are interested in here from my perspective has to do with exercises and I am going to get to exercises and devote most of my time here to exercises, but I first, I just want to go through the, in addition to talking about exercises, I would also like to go through just a little of the evidence that's out there for physical therapy and exercises regarding this condition. And then also to touch on how to include physical therapy in a care plan for a patient when they are having some symptoms or even before the device is inserted. So, um, Shuba mentioned this fantastic review article, and I was so excited that physical therapy was included. And I just wanted to make mention of the specific ways that physical therapy can help here is with the palliative care. There is some evidence looking at isometric and passive jaw stretching. So isometric for those who might not know is adding a little bit of resistance that your muscles are trying to balance your force. And I will talk about those later. Passive jaw stretching is where you're using fingers to stretch. You're not using your own muscle force to stretch. And then the review article also highlighted that physical therapy can address the temporomandibular joint pain, and it can actually also have a little bit of an effect with occlusal changes as well. And most importantly for me, especially because I am also a second year PhD student here, this review article highlighted the literature gap regarding treatment guidelines, as in there really are no very distinct guidelines here. So sometimes we feel like we're flying blind, but there is some evidence for exercises for pain resulting from oral appliance therapy. And this article by Canale was in Brazil and they had 32 patients that were diagnosed with sleep apnea, as well as temporomandibular joint disorders. And then they randomized them. They had half in a jaw exercise group. So the first one is this rotation with your tongue up, then BC and D there are the isometric exercises side to side and then underneath. And then finally E is the passive jaw stretching with fingers. The placebo exercise group was neck stretching. And then they started using the device. They did their exercises. I believe it was three sets of five repetitions twice per day, followed them monthly. And then at four months, they found that there was significantly decreased pain in the jaw exercise group. So comparing to baseline pain. So on the right, the jaw exercise group, the final to baseline and their average intensity of pain. And so this article highlights, as Dr. Geary was saying, the importance of screening patients for TMD and that having a diagnosis of TMD is not a contraindication for using a mandibular advancement device, because there are exercises and ways that you can manage to help with that condition. So then this next article by Ishiyama from Japan and his colleagues, they looked at people who did not have a diagnosis of temporomandibular joint disorders. They did have sleep apnea. And so they started them on exercises before they used a mandibular advancement device. And the jaw stretch group, the top there, they were doing this passive stretching and then the placebo group did neck stretching. So then after two weeks of exercising, they gave them their advancement devices and checked in with them every two weeks looking at pain and sleep quality. And they found that pain did occur in both groups and that pain resolved by three months. So after three months, everybody did get better, which is consistent with some of the other evidence that we see. They also found that both groups had less apnea using these devices. At one month though, they found that the jaw exercise group did have significantly less pain with jaw opening and chewing. They also found that the jaw exercise group had better REM sleep. So their conclusion was that jaw stretching can perhaps improve the adaptability of those muscles and maybe even decrease the risk of injury. So physical therapists, and there are specialized people like me who treat this. I just wanted to talk about the thought process I go through, because when people are wearing these devices, I'm thinking about that lateral pterygoid muscle and how the advancement is going to affect the lateral pterygoid muscle. So one of the first things that is done with every single patient and is the most helpful, and I think definitely as Alex was mentioning, can be done in a clinical setting from the providers as well. But talking about the rest position of the jaw throughout the day should be with the tongue up, the teeth apart, slightly hanging your jaw open. And when we're in that position, we get nice relaxation of these facial muscles. We can use that position as a check-in throughout the day in the same way we check posture. Is your head forward? Are you slouching? We want to be in this nice neutral position because, and especially when people have had their jaw forward in that position throughout the course of the night, those masseters start guarding and clenching. Then there's clenching that happens anyway if people are biting their fingernails, chewing their lips throughout the day. Teaching your body to go back to this rest position can help to mitigate the effects of the increased muscle tension that might be happening once they add a mandibular advancement device. Another element of self-care and joint protection that we discuss is posture. Maintaining an upright posture helps, excuse me, produce this balance between the head and the neck, and it decreases some of the strain on the jaw and the cervical muscles. When we slouch and our head starts to come forward, the jaw is affected and can increase some of the muscle tension habits that we have as well. So in addition to making sure we preserve tongue up, teeth apart, we also need people to look at their overall head and neck posture, and we can do exercises for that as well. We look at, you know, how do you decrease lateral pterygoid tension? As Alex said, it is very difficult to get in. We can't do this really nice, convenient trigger point release like we do with some other muscles that are easier to access. And when we get spasms, especially in the lateral pterygoid, we start seeing that the opening patterns change. It might exacerbate clicking, even locking. Sometimes the spasm can mimic a hypomobile capsule closed lock. So we look at retraining tension by looking at how can we help to retrude the mandible, and I'll get into those exercises on the next slide, but then also looking at the opening pattern, and have they started to reverse that process? Are they thrusting forward before they start opening? Do we need to restore controlled rotation? And then additionally, like that other article showed, we work on adapting those muscles to tolerate the effects of the appliance holding the muscles forward. Ultimately, our primary goal is that we want to ensure that patients can continue or resume use of their appliance. We want to help set them up for success, and just because they have symptoms doesn't mean they need to toss the appliance to the side. With some management, they really can have very good outcomes and use that appliance as intended. So the pictures here are my three most favorite exercises that I use, and we will be going through them all together here, but again, I just wanted to highlight that symptoms can resolve with self-care and physical therapy, and that's an important piece to educate patients about, and that the thing with physical therapy is that we focus on an individualized rehabilitation program based on the goals and symptoms. And I so desperately want to have a list to tell you, all right, you give them these five exercises, they started before the appliance, you're good to go, you won't have any problems. But because we do need to tailor the exercise program to the patient, so I just don't have the ability to say that, or if I did, I think I would be doing you all a disservice. So yes, we do manual techniques. We can do some intraoral massage on that tight masseter, the origin of the masseter. We can do cross friction massage intraorally on the temporalis tendon. We do a lot of manual work for the cervical muscles as well. We do postural exercises, including good old chin tucks. We do scapular retraction. Getting though into my favorite exercises here, the top picture is called controlled rotation, and this isolates the rotation component of opening. And you can perform it with your fingers in front of your ears, and I encourage you to try this right now. Your tongue will go on the roof of your mouth, and as you open, you're going to try and direct your chin down and back towards your throat. So you're opening with almost a component of retrusion to isolate rotation so that you do not feel that forward translation. And by opening and closing, this gets back to the idea of keeping the jaw moving. It's like you're pumping your jaw in a protected range. It really forces the lateral pterygoid to inhibit itself so that we can reduce that tension. The bottom right here is the isometric exercise where you have the jaw hung up in a neutral position. You're adding just a little bit of resistance. My finger is blocking the jaw from moving toward it. But you cannot use 100% effort. So go ahead and try it. Just a little bit of activity. You're engaging the opposite pterygoids, and it causes a little reciprocal inhibition on the same side. If you push as hard as you possibly can, you're essentially just bracing all of your muscles and you're not going to be targeting those muscles in question. If you have an overactive lateral pterygoid, doing that isometric exercise on the same side asks the opposite one to engage and it forces that spasming one to decrease. So you can do that side to side as well as underneath, holding about three to five seconds in each direction, but it has to be minimal. I tell the patients one to five percent effort to ensure that you're not going to overdo things. The retrusion exercise, so I have a lot of people who have been trying to use that good old morning positioner, repositioner to get their jaw back in place, but if you have a lateral pterygoid that's in spasm, it is not necessarily going to allow them to retrude back to where their repositioner wants them to be. So one of the things I do is I either give them a little piece of rubber tube or they can do it on their finger and you can do more graded retrusion work. And so I'll just demonstrate it here. By watching in the mirror, they can see how much they're moving. It helps improve that coordination between their brain and their muscles. The pterygoids have about 90 percent of all of the proprioceptive sensory receptors in the body. So when that's in spasm, they really don't know where they are. They can't move side to side without assistance. So then this also works for training lateral trusion in a very graded way. And they can watch in the mirror to see, is their jaw protruding forward? Can they retrude and maintain that in a good position? Again, you can also do it on your finger. And then finally the last, the progressive jaw stretch, that picture in the lower left, is you can start with one finger or knuckle and you can work your way up to where it feels comfortable for stretching. So then ultimately, it just goes without saying, we need more randomized control trials to develop evidence for the role of exercise, physical therapy or not, but also physical therapy. And then in terms of what to tell your patients initially, that self-care, whether it's tongue of teeth apart or just noticing jaw habits, self-massage, heat, ice, everything Alex was saying, that I think should just without question be something that is given to people. But then also that gentle progressive stretching with the finger of the knuckles, the isometric exercises, just makes sure that they're not doing it at maximum effort. But again, I just want to highlight that tailoring those exercises to people individually is the important piece. Anyone can go online and find exercises, but they can overdo it. They can hurt themselves. And so then just also educating people to know that management options do exist. And then to find physical therapists here, you can always contact local clinics, ask about orofacial pain specialty expertise, or just experience in that area. The AALP, the Academy of Orofacial Pain, does have a group. It's the Physical Therapy Board of Craniocervical Therapeutics. And there is a directory online. And so I am very quickly here going to show you. There we go. So hopefully you all can see this right now, but this is our website and you can go to the member directory. And it's slow, but the member directory has all of the people who have taken the specialty certification exam. And you can look by name. You can look by affiliation. You can also search then by state. So I could search, for example, Wisconsin. Oops, it's not letting me do that here. There we go. Okay. So you can choose your state, Wisconsin, and then it will pull up all of the people who are certified in that area. And this can be valuable because if there's no one specifically in your area, but maybe you want to find somebody who's nearby, you can contact them because there is contact information provided. And you can say, I'm looking for somebody in this area. Do you know anyone? Do you have any contacts? Because most of us, it's a small enough community. There's only 56 of us. So we can, we direct you somewhere for that. What are some red flags found during pre-treatment exam that would point to addressing the TMD issues before embarking on oral appliance therapy? I guess I would ask that to Dr. Giri. Okay. I'll begin with it. And then, of course, feel free to chime in with Alex and Emily there. I would say, as I looked at the TMD pain screener, we looked at it together. Any evidence of pain, functional limitation would be the first thing to ask about our good clinical history as Alex was talking about. It should be part of our intake, just like we screen for Epworth and sleep disorders. I constantly use the TMD pain screener. Every single patient gets those questions. Have you had pain in the past 30 days? Have you had a functional limitation where you cannot open your mouth or you have pain with function or chewing on something tough? Have you noticed jaw joint noises? And so we start asking these questions as part of our intake. And that becomes a screening tool in identifying it early. And those are the red flags. And in the absence, I recently had somebody with significant early onset Alzheimer's and her symptoms was no pain. But then when I go to examine her, she would just wince and move away. And then there we have that tenderness. And there we have that history. And the husband is now talking about, oh, you know, she just switched to oatmeal the past month because she can have her cereal that wasn't soaked yet and things like that. So you start investigating from that standpoint. But as a screener, definitely the TMD pain screener, it has been a very valuable tool for me. Yeah, I want to add to so red flag has a very different connotation with an oral facial pain versus dentistry. And again, I don't mean I mean, oral facial pain is within dentistry for sure. But I mean, general dentistry. And to us, when you say red flag, I'm going to immediately think of my red flag headaches, my patients that present with these things that are get them to the emergency room today, or tomorrow, because they may die in a week. You know, and so to me, red flags are these, these, these, okay, are we looking at an aneurysm that could burst? And so in sleep, I'm going to be honest, I don't believe there are red flags. And so like, like Suba was saying that, that these are the conditions that to me are yellow flags. They're, they're, they're flags that are, hey, consider this, but also consider their whole person. And I'm not trying to suggest that Suba is not, obviously she is. But my point is, there are very few red flags of do not treat this patient, period, in, in oral facial pain or, or sleep medicine. These are very, very fluid conditions. So in that patient that, for example, geriatric patients are one of my favorite patients to treat that my residency was in a geriatric clinic. And so these patients are very different in terms of what we're used to compared with a 40 year old, you know, these are an oxygen area, and it's very different than someone in their forties in that we're managing very different conditions, very different presentations and very different ways that the patient discusses with you. And so treating that patient is on a spectrum. So can we improve their pain? Maybe, maybe not. Is our treatment going to worsen their pain? If no is the answer, then sometimes we have to live with they have the condition they have. And sometimes we can improve the condition they have. So in these, in these red flag conditions, what I'm looking for is, is an absolute contraindication. Do not treat this patient is very few and far between on the sleep side. Now, having said that, if I've got a patient that doesn't seem like they can have the range of motion, that's going to be appropriate for sleep appliance. Absolutely. They should do CPAP first. Have they failed CPAP? Well, then we need to treat them with a sleep appliance before we go down the route of maybe inspire where we're talking about a surgical procedure on a 90 year old, you know, yeah, their range of motion is four millimeters. Great. Let's get them to four millimeters and see, does their sleep improve? If not, okay, now look at the surgical route. And so it's, it's, it's very much a balance as opposed to kind of everything else we do in dentistry where there is a good cut and dry. And on that note, physical therapy can absolutely help improve that protrusion range of motion. So it might even be as, as few as a few sessions can, can help get them to where then, oh, now they can open for impressions and they can tolerate some advancement. And, and remembering too that, yeah, sleep is not going to kill you in a night, right? I mean, at the end of the day, sleep apnea is not going to kill you tonight. It's going to kill you 10 years from now or 30 years in the past, if you had treated it right. And now we're dealing with epithelial dysfunction and all the, or endothelial dysfunction and all this issue. But at the end of the day, if we have to defer for five, six months to go through PT to improve range of motion, that's fine. I mean, a patient is not going to die overnight from an apnea event. If they are, are stroke risk, that was from apnea 30 years ago, not today. So, so deferring to PT is, I think something that, that we need to get comfortable with. Great. Thank you. The next question, I think it's almost like a follow-up to this question. What are some findings that a TMD symptomatic patient should be referred to a specialist, whether it is pretreatment or during oral appliance therapy? Alex, you want to take that one just from a clinical space? Yeah. So, so realistically when to defer, when to refer, no different than anything else. If you're comfortable treating it, treat it. When your treatment doesn't work and you don't know what to do anymore, send it off. The beautiful thing about oral facial pain is rarely, rarely are you going to harm the patient by trying something, as long as it's reversible. You know, I'm not suggesting you go and do a discectomy and do anything crazy surgically. Not that a discectomy is crazy, but, but, but when you're doing reversible treatment, try. Let's be honest, at the end of the day, that's what we're going to do. If you refer them to me, I'm going to try. I certainly can't magically know what to do. So, so when you've tried everything in your toolbox and now you go, okay, you know what, maybe you need PRP in your joint. And I'm not comfortable doing PRP, or you need a joint injection of any sort, and I'm not comfortable with that. Yeah, send off then, and then I'll happily do that. But, but this is not a complex issue. Take care of your patients, do what you're comfortable with, and when you're not comfortable, refer. I would just add to that, Alex, just to comment that, let's think back to that closed-lock paper, which is very, very recognized. Let's recognize that 50% or more patients with acute onset, limited mouth opening, functional restrictions patients, so acute TMD joint symptoms, responded with medical management and self-care and patient education. So let's start there. I think that is an area of comfort. We can hone our skills there. We can educate ourselves and get really comfortable with it. And then anything beyond that, we can start adding on strategies. And then as Alex was saying, I really agree with that level of comfort and then refer out. Definitely partner with your local orofacial pain expert. Definitely have a collaborative relationship. I think we need to get to that comfortable space where we are all interdisciplinary, collaborative clinicians. That's how the physicians work, right? I mean, a primary care physician is going to reach into the neurologist or a sleep physician, and they're going to partner. So let's all get comfortable with collaborative care. Yeah. Great. Thank you. We've got a few more minutes here. We're going to ask the next question to Emily. Should we always give exercises before patients begin using devices? So I think, as I mentioned, the self-care discussion and education component definitely always needs to happen. It gets a little fuzzier beyond that because, again, you don't want to just give people a list of exercises. It's not one size fits all. So if it's somebody where their range of motion does seem a little bit limited, again, going back to then the idea of the screening, the importance of the screener, then they might be someone where the stretching with the knuckles is helpful. If it's somebody where they don't have any symptoms at all to begin with, you don't necessarily need to. Yes, there is that exercise showing that jaw stretching has the chance, the potential to help. So in that case, sure, it's up to you. I'm not going to say that if you don't give these exercises, it won't be successful. But again, just highlighting that idea of the screener, and then if you have some exercises sort of in your back pocket that you can pull out maybe at that first follow-up, or you could say, you know, jaw stretching sometimes has shown to be effective. Try it out. But sometimes you don't need to overdo it because people can just go to town and start overdoing it themselves and then create pain when you don't know if that would have happened before or not. So yeah, just use some judgment there, but don't be afraid to try. We see in pain especially, you have a high of what we call nocebo response, and I don't mean to try and talk down to people if you learned this in school. I did not. I did not learn what the phrase nocebo meant until I went into residency, but this idea of placebo, we're all used to, right? Like they get better even though they have a placebo. Nocebo is the same idea. It's just the reverse. You get worse. So if you tell a patient the side effect of the med and they all of a sudden have every side effect of the med, that's a nocebo response. And you can have that especially with exercises. So if you tell a patient or any of our treatment, I don't mean to highlight exercise, but if you tell a patient to do something and they're a patient that's maybe more inclined to have these maybe overdoing sides, you can very quickly in your quick two seconds, because you're not going to go into the detail because it's a two second delivery. You're going over the quick, okay, stretch in the morning when you wake up. If you don't take the time to explain how to not overstretch or overdo it or what is too much, then it is very easy to push that patient too far. So it is certainly a balance of don't just throw out, here's your list of exercises that every patient gets. It does need to be tailored. And I think there are some that are safe for sure. Like don't open, leave your tongue on the roof of your mouth and don't open past that point. I don't think anyone can mess that one up. My safe exercise that I give every single joint patient without fail is what I call my ya-yas. And I got that from a much smarter patient than me. And that's why I always say trust your patients because they are a hundred times smarter than any of us are. But it's a joint, a jaw hinge exercise of gently opening the jaw, rotational only movement, preventing any translation. But I had a patient who translated and said, okay, well, that's like just saying the word ya-ya. Perfect. So say ya-ya a hundred times a day. Like that's never going to hurt a patient, but at the same time, you don't necessarily want to give it every time. But it's these safe exercises that you can kind of throw out. And then other exercises, yeah, hold for appropriateness would be kind of my view on it. Well, great. I see we are past time. We have one more question. We take one more question. What is the difference between a myalgia and myofascial pain? And does it matter from a treatment or recovery standpoint? Okay. I'm going to take this opportunity and advertise one more time. DCTMD, the appendix lays out exactly what you're asking. What's the difference? Well, if you go find that paper tonight, you're going to be so happy because, okay, I will go up over it briefly. Myalgia, tender muscle, and then palpation of that muscle duplicated pain. Simple enough. Myofascial pain, you have to find a taut band and that taut band duplicates the pain and it's considered a trigger point. And that's where you're identifying it with connected trigger points in the cervical area. You're identifying it in a temporalis area, masseter. So specific spots where the active trigger points can be located in these muscles. And so myofascial pain ties to that. And so there's more to it, but I would really rely on it. That's a fantastic reference for us to hone in. And I'm really appreciative of the fact that you want to hone those things. You want to separate them because then you know the trajectory of the diagnosis is different. And this is kind of a tag along to what Emily responded to earlier. When we talk about patient education, diagnosing it early in the screening time, telling the patient, education the patient, what you have is this. This is the condition you have. It is myofascial pain. This condition is chronic recurrent. It exists independent of your oral appliance therapy. Let's give you some strategies to tackle it ahead of time. Let's give you some preparatory things you could do to set you up for success with the oral appliance. Let's also recognize it's chronic recurrent. It has its own path. And as the oral appliance comes on and you have symptoms, let's treat them as independent and manage worthy of the chronic issue. Very good. Yeah, if I can tag on that. So suicide is very, very key. Naming the condition is magic. So we didn't get into this at all in this discussion, but we have this model that, and I don't mean we as in orophasial pain. This is the generally accepted model of all pain medicine right now is this biopsychosocial model. This idea that pain is biology, nerve sensation, sodium channels opening, voltage gate, volt goes up the nerve, the brain interprets it. That's the biology. But when you look at the brain and how it interprets it, the very first stop when it enters the brain is our hypothalamus complex, where we're looking at this, coding that pain signal almost in a candy coding, right? This is the idea of like an M&M, right? It's candy coated. That's what it is. And that's what pain does. Once it hits the brain, it gets coded by the psychology, sociology, history. The example I always do my patients is as I talked to you about touching a stove and burning your finger, I promise half of the people on this lecture right now, immediately flashback to their childhood, touching a stove. And you remember what that element looked like on the stove and how red hot it was, right? That's your brain protecting you from pain. And when we combine all these elements together, we get an idea of what pain is. And so when, when the brain can't comprehend the pain, it gets very confused. And all of a sudden that pain signal gets just blown up. And so naming the pain and giving the patient this idea that your pain is this is magic. And so starting your treatment with saying, I've noticed this is going on in your muscle. And I'm not saying you need to call it, you know, like I literally a name, like a person's name, like this is the Vaughn, you have Vaughn pain right here. Like, and that's not what I'm saying. Like just giving it an idea of you have muscle pain or myalgia, myofascial pain or myofascial pain syndrome is very dramatic in how much that improves a patient. And you see this in cancer as well, when you can name the cancer and you can explain the progression of that cancer, not just cancer, not lung cancer, you know, you have carcinoma or whatever we give it this name. And it, it is a thing is magical for patients. So, so going in and giving them that, that foundation, I see this, I expect this in your treatment and we're going to manage it. You will get a hundred times better result on the same patient than if you just said, you might have some pain, we'll see what happens. You know, and that, that giving them that confidence and comfort and you as a provider, you've, you've, you've cared for them. You've recognized their problem and you're going to manage it. You're going to resolve half your problems before you have them.

TMD symptoms

oral appliance therapy

screening

self-care strategies

exercises

tailored approach

myalgia

myofascial pain

treatment and recovery

biopsychosocial model of pain