CATEGORY AUSTRALASIAN DENTIST 87 LINICAL while the dentist fits the splint the dental assistant reads out loud the instructions to the patient and the dentist, and when necessary, the dentist may interrupt to explain a pertinent point. Following the appointment, the patient leaves with the reference handout. This acts as an aid to memory and enables them to confer with their family or friend. A dentist in a group practice treating another dentist’s patient and not familiar with instructing a patient on how or why to use a splint, can also refer to the handout section entitled instructions for dentists (Table 1). Sleep posture analysis Patients with TMD often have difficulty sleeping and many injure themselves at night performing parafunctional habits (Colquitt 1987). In 1992 a TMDpatient, with unresolved symptoms, admitted to sleeping on her fist (Fig. 23). This was followed by the author’s initial sleep posture analysis. This revealed that one of the patient’s knuckles was penetrating deep into the left TMJ fossa helped with the weight of the skull over that fist. Following this the author has regularly performed sleep posture analysis, when it seemed to be a possible culprit. Sleep posture analysis has usually been performed during one of the splint adjustment appointments and the salient points have been outlined in point six (Table 1). This primarily occurs after the patient admits to difficulty in sleeping or some of the unresolved symptoms can be traced back to a detrimental sleep habit. The process starts with the dental assistant placing a blanket and pillow on a carpeted floor and asking the patient to lie down on their back. The patient is asked to move to their favoured position. If it is on their front or abdomen, the patient is asked where strain or pain is present in their head, neck, and shoulder regions (Fig. 24). The patient is informed that the weight of the skull can be transferred to the chin on the bed which in turn pushes the lower jaw backwards and sideways into the jaw joints. This will result in stretching of the TMJ ligaments and can eventually result in a displaced clicking/locked TMJ disc and strained/painful facial and neck muscles. The patient should be advised to desist from sleeping on this front position and to always start the sleeping process by lying on the back and to always roll from side to side via their back not via their abdomen (Fig. 24). Patients should be encouraged to where possible sleep on their back. This starts with pulling the pillow under the head and engaging the neck and shoulders firmly. Placing the arms each side of the body with the hands flat and the legs outstretched. If the patient feels the need to move the patient is recommended to raise the knees up and place the feet flat on the bed or sleep on the side. The patient is then asked to turn to a side that feels comfortable or favoured side (Fig. 24). With the head on the pillow and parallel to the floor, the patient is asked to tilt the chin slightly towards the floor to relax the neck. At this stage unusual, strained positions of the hands, arms, neck, and shoulders relative to the pillow and the relationship of the hips and legs to the spine are noted. Instructions are given to the patient to place their hands and arms in the following recommended positions, point 6 (Table 2). Sleep with the left hand flat under the pillow when lying on the right side and right hand and arm towards the same thigh/knee region and vice versa. The flat hand underneath the pillow is used to push-off when cocking the shoulder or lifting hips during body adjustments. The patient is instructed to slightly cock the shoulder, above the blanket, so that the weight bearing point of the shoulder becomes the fleshy side of the shoulder and not the tip. The patient is then asked to momentarily lift their hips above the blanket aided by pushing against the blanket with the flat hand and placing some of the forearm under the pillow and re-position their body with a wriggle into a comfortable position. At this stage, the body while lying on a relatively hard surface should be supported evenly and comfortably over several weight bearing points. Concomitantly, the shoulder and lower jaw will be supported by the contralateral hand which must be flat or slightly cupped (never in the form of a fist) under the pillow as illustrated (Fig. 24). This hand can be placed anywhere under the pillow including the end of the pillow to be supportive of the shoulder, neck, and jaw. Patients should be encouraged to, where possible, start the sleeping process on their back and if this fails rollover via their back to their non-favoured sleeping side, and if this fails roll over to their favoured sleeping side. This process is B. FOR DENTISTS ‘TO DO’ LIST 1. Do emphasize that the splint is primarily designed to ‘RELAX OFF’ from hinge occlusion and ‘not clench or grind on’. 2. Do instruct that tapping the lower back teeth on the back of the splint several times in hinge bite is recommended. This must be followed by opening in the hinging arc and remaining open between about 1 to 10 mm apart anteriorly. This is the rest position of the jaw when wearing the splint. Occasionally, tapping in hinge occlusion to confirm where the lower jaw is positioned in space is allowed and recommended. 3. Do show the patient the canine rise and edgeto-edge protrusive landing pads. Ask the patient to move from hinge occlusion along these three protective paths to the pads and then ‘slippery slide back’ or re-centre into hinge occlusion. 4. Do demonstrate to the patient how these three anterior lumps on the splint restrict and re-centre the lower jaw during excursive movements. They also act as ‘pillows’ during sleep to support the lower jaw, often in the region of mid-lateral and mid-protrusive paths. 5. Do ask the patient to place two fingers on the skin in the region of the TMJ fossa whilst moving their lower jaw to the three landing pads. The patient will feel the condyle leave the socket and only once carefully request the patient to move just past one of these pads and to note the TMJ strain and/or pain. Emphasize to the patient that these pads represent the end point of the safe zones of the splint and the safe ligamentous boundaries of the TMJ’s. Table 1. ‘Full Counselling’ instructions to patients and dentists for fitting a ‘Fully Protective Occlusal Splint’. A. FOR PATIENTS ‘TO DO’ LIST 1. Do wear the splint every time you sleep. 2. Do try to find two hours during the day to wear the splint. 3. Do wear the splint most of the day, if required. ‘NOT TO DO’ LIST 1. Do not wear the splint the entire day except if the patient feels the need. 2. Do not eat with the splint. 3. Do not suck, flick, or press the splint with your tongue. ‘NOT TO DO’ LIST 1. Do not allow the patient to think that persistent resting, biting, chewing, or grinding on the splint is recommended. 2. Instruct the patient not to advance their lower jaw past the landing pads which is called ‘crossover’ as this will stretch the TMJ ligaments and potentially displace the TMJ discs.
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