Home Care

1. Instruct the patient to follow a soft food/no-chew diet for approximately one month. This will include avoidance of foods of various textures including:
- Chewy foods, e.g. sourdough bread crust, pizza and steak.
- Hard foods, e.g. carrots and hard candy.
- Sticky foods, e.g. gum or caramel.

2. Instruct the patient to use a soft, cold compress over an inflamed temporomandibular joint 10-15 minutes per application, 3-4 times per day. Your examination should enable you to accurately identify joint inflammation and thereby guide this recommendation. For inexpensive, effective tools for examination as well as products that will help patients follow your home care instructions, e.g. cold compresses, click here.

3. Instruct the patient to avoid wide mouth opening, especially of a prolonged nature. Specific instructions include suppressing yawning and to avoid dental visits other than those which are deemed to be medically necessary. The patient can suppress yawning by either putting their hand under their chin when they yawn or lower their head toward their chest when they yawn. While both techniques work the whiplash patient may best be served by using the hand under their chin so they don't strain their neck.

4. Instruct the patient to avoid repetitive and/or expressive speech. (In severe cases the patient may have to be placed on temporary disability depending upon their job description.)

5. Instruct the patient to avoid clenching. Patients are frequently unaware of any tendency to clench their teeth and, in fact, may only develop this tendency secondary to a whiplash injury or other traumatic event. Instructions to avoid clenching in the early phases of the disorder may well serve to modify this perpetuating influence. One simple suggestion is to have the patient focus on keeping the lips together with the teeth apart and having the tongue rest on the roof of the mouth.

Nutrition

While much of what we have presented in this website has emphasized the mechanical, neurologic and muscular issues of TMD, inflammation of the temporomandibular joints is what drives most TM joint driven disorders (see TMD Training System for graphic pictures of inflamed TMJ's viewed through the arthroscope during surgery). That said, nutritional advice should be incorporated into any TMD treatment plan. The nutritional suggestions should address at least these two issues:

1. Control of inflammation
2. Maintain optimum health while on a soft food diet including a high quality protein drink/meal replacement

Obviously there are many nutritional needs not mentioned here, but these two factors should always enter into case planning. Please contact me for suggestions about products that satisfy these needs and have proven to be effective in management of TMD.

Physiotherapy

The information in this section will be of most use to those health care practitioners who know how to do a thorough exam and make an accurate diagnosis. The training necessary to perform an accurate 5 minute exam, which will effectively guide your treatment and recommendations, can be found in Dr. Steigerwald's TMD Training System. This tool not only demonstrates and describes examination techniques but trains you in TMJ manipulation/mobilization. The video/workbook will also help you locate the source of the symptoms and identify the pathology. Upon completion of this physical management section you will see that the suggested treatments are simple, time efficient, effective and billable.

TMD surfacing following whiplash is frequently a result of an injury to the temporomandibular joint complex. Pain and/or stress mediated clenching may onset or escalate following the whiplash event and aggravate the injured tissue. While these joint injury cases require diagnostic accuracy, relatively simple steps taken soon after the injury may intercept a degenerative process that might otherwise become disabling.

Treatments for the TMD range from home care to surgery.

Physiotherapy treatments for TMD and related head and neck disorders should be tissue, pathology, depth and stage specific. When they are, and state of the art technology is correctly applied, treatments are simple, time efficient, effective and billable. One example of a state of the art physiotherapy delivery system, Solaris, is pictured below. It makes phototherapy (light therapy), electrotherapy and ultrasound (pulsed & continuous) available in one unit. All of these modalities are useful and effective for the treatment of TMD.

PHOTOTHERAPY (Light Therapy)

Phototherapy (light therapy) has proven to have a wide range of positive affects on the repair and regeneration of tissue without raising tissue temperature. Wavelength determines depth of penetration with deeper penetration associated with longer wavelengths. The picture below is of a patient being treated with the phototherapy applicator of the Solaris physiotherapy unit (suggested dosage: 1-3 J/cm). I suggest using phototherapy (light therapy) immediately following distraction/mobilization of the TMJs. When you have completed the distraction/mobilization procedure, place cotton rolls between the patients' upper and lower molars to keep the joint distracted/unloaded during the phototherapy (light therapy) application. The same technique can be used for pulsed Ultrasound applications.

ULTRASOUND

1. Pulsed ultrasound at 0.3 to 0.6 watts per sq cm over the lateral poles of the temporomandibular joint condyles with a small sound head for 2 to 3 minutes per side. The more inflamed the joint, the lower the ultrasound setting should be. If any temporomandibular joint- or ear pain is reported by the patient after Ultrasound application, this treatment should be discontinued for four to five days. Depth of penetration will range from 3 MHz for superficial capsulitis to 1 MHz for internal joint synovitis (Solaris is the only Ultrasound unit to offer choices of 1, 2 or 3 MHz).

2. Continuous or pulsed ultrasound for tender masseter and anterior temporalis musculature at 2 MHz / 0.5 watts per sq cm 3 to 5 minutes per side depending on area to be covered. This modality is most effectively applied at muscle-tendon-bone junctions.

3. Simultaneous (combined) application of ultrasound (1 MHz pulsed-0.6 watts per sq cm) and modulated direct current (skin stimulation to a sensory level-noncontractile) over trigger points. Place a small to medium size pad over the foramen of the vertebral motor unit for the dermatome of the trigger point, or over the ipsilateral temporomandibular joint, and use the sound head as the active electrode. Choose the vertebral segment or the temporomandibular joint according to which is most likely to be affecting the muscle in question. Treat the trigger points for approximately one to two minutes each during light intermittent passive stretching.




ELECTROTHERAPY

1. Galvanic and modulated direct current stimulation can be used over the lateral capsule of the inflamed temporomandibular joint at a comfortable sensory level for 8 to 10 minutes. The dispersal pad should be placed on the ipsilateral cervical region.

2. Medium frequency stimulation to the muscles of the mastication when joint inflammation is not considered the dominant process. This is best achieved with modulated medium frequency current productive of muscle tremor rather than full muscular contraction. This is applied for approximately 10 minutes per treatment. Modulation between 10 and 25 Hz is very effective. Lower frequency modulation, e.g. 3-10 Hz has also been used effectively.

DIATHERMY

Only pulsed diathermy should be used over and around the temporomandibular joints when joint inflammation/effusion is suspected. Treatments usually range from 6 to 10 minutes per side with settings of 15 to 30 watts. Duration and intensity should be inversely proportional to the degree of inflammation in the joint. This is an ideal treatment for the acute inflammatory response to injury.



MICROCURRENT STIMULATION

Microcurrent stimulation can be used with either pad or probe technique for dysfunctions of the temporomandibular apparatus. Various protocols are cited for this type of treatment. Some of the more popular involve probe stimulation of accupoints with biphasic microcurrent at settings from 0.03 up to 6 Hz and generally at low outputs of approximately 25 micro amps. These accupoints are stimulated for anywhere from 5 to 30 seconds. Microcurrent can be delivered to the temporomandibular joints locally by placing the pads over the preauricular regions and using settings of approximately 25 to 75 micro amps at 0.03 to 6 Hz for 10 to 15 minutes. Once again, this is a biphasic current setting. In treating one temporomandibular joint and an area considered to be affected by inflammation in this joint such as the ipsilateral cervical or upper trapezial musculature the biphasic mode may be abandoned and the positive pole placed at the temporomandibular joint proper with the negative pole placed at the temporomandibular joint proper with the negative pole placed on the affected region.

CRYOTHERAPY

Cold compresses can be effectively used over the inflamed temporomandibular joints 15 minutes per application following other therapeutic modalities. Instructions should then be given to the patient to continue cold compress application at home 3 to 5 times per day depending on the degree of inflammation. It must be considered here that the temporomandibular joints are very capable of maintaining a perpetuated, acute, inflammatory state for some time following the actual precipitation of the inflammation. Acute inflammations have been observed arthroscopically in temporomandibular joints injured some 14 months prior. This should be considered when any form of physiotherapy is applied with specific reference as to the benefit of heat vs. cold.

Please refer to the TMD Training System for training in
examination, diagnosis, manipulation and physiotherapy.

Questions?
Email Dr. Steigerwald at: info@whiplashandtmj.com or call 631-749-1534 (NY)

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