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TMD Problems – When Telemedicine Isn’t Enough

TMD Problems – When Telemedicine Isn’t Enough

Author: Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain

Date: October 1, 2020

For the past few years, telemedicine consults have proven to be extremely effective in assessing and beginning treatment for patients suffering from orofacial/TMD problems.

Whether the patient’s problem is of muscle, joint, or neuropathic origin, the history and symptoms communicated typically provide enough insight to begin the process of educating, allaying fears, and providing strategies of self-care. Often, just telling a patient that their problem is common, familiar, and helpable is all that is needed to create optimism and confidence that they can get better.

At times, however, despite time spent with a patient online and gathering information that seemed complete, an accurate diagnosis was not made, and symptoms persisted until an office visit was possible. One particular case study reveals this reality.

Case Study – William

William, a 15-year-old male, was initially assessed in May 2020 via a Zoom consultation. He related that he had been unable to open his mouth for the better part of a month, which he called “lockjaw’.” Apparently, prior to the lock, which occurred suddenly, he had experienced intermittent clicking in the left TM joint during eating without pain.

When he attempted to open his mouth wider, it would not go any further, and there was acute pain on the left side of his jaw.

He had been involved in fixed orthodontic treatment for the better part of two years but had not been to his orthodontist for almost three months due to the COVID -19 pandemic. While his medical health was unremarkable, he did report a history of nail-biting and day clenching.

Virtual Examination

A virtual examination revealed limited jaw opening with a left deflection. Jaw opening was approximately one fingerbreadth that likely would have measured 15-20 mm. Movement of the lower jaw to the right was markedly limited with pain on the left side. Self-palpation by the patient revealed muscle and joint tenderness on the left, and masseter hypertrophy.

Based on the history, symptoms, and limited examination, it appeared that William had a disc interference disorder in the left TM with associated inflammation and muscle guarding.

Though it was unclear why a benign click would have progressed to a profound anterior disc displacement restricting jaw motion, treatment options were offered and pursued. They included a combination of muscle relaxants, anti-inflammatory medications, jaw exercises, dietary caution, and strategies to stop William’s jaw overuse habits of nail-biting and clenching during the day.

Despite those efforts, William reported no improvement over 4-6 weeks.

When MRI appointments became available, a scan of William’s TMJs was obtained but revealed no anatomic disruption in either TM joint. Therefore, my working diagnosis of a disc displacement being responsible for his limited opening and pain was incorrect. It was time for an office visit.

The Office Visit

On July 10th, William was seen in my office. His limited jaw motion was profound, measuring 18 mm with a “concrete” end feel. All the jaw muscles were tender on the left, but the joint was not.

An intraoral exam was limited, but my first glance revealed upper and lower bonded orthodontic brackets and archwires. However, the archwire no longer engaged tooth #30 and tooth 31. It was missing.

In fact, the archwire had slipped out of the brackets and moved laterally to the left, distal to #18 and #19, piercing the cheek, and essentially impaling the buccinator and masseter muscles leading to, what I suspected, was a traumatically induced trismus.

How William tolerated this wire embedded in his cheek for several months is remarkable.

Upon removal of the wire, there was an immediate increase of jaw motion moving towards 25 mm. A five-day regimen of precautionary antibiotics, anti-inflammatory medication, and jaw stretching exercises was all that was required for full recovery of jaw function and pain resolution.

Conclusion

I believe telemedicine consults are here to stay. They allow immediate patient assessments when office visits are impossible or contraindicated. Nevertheless, there are times when things are not what they seem to be, and in-person evaluations are essential.

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