CATEGORY 88 AUSTRALASIAN DENTIST LINICAL encouraged because sleeping on the back is the least detrimental to the jaw joints and learning to sleep on your non-favoured side encourages sleeping flexibility in the event of a restrictive ailment on the favoured side. Adjunctive therapies Adjunctive therapies were used to compliment occlusal therapy. A number are presented in Table 2. Many adjunctive therapies have been found to be harmful or futile andwere excluded, some best avoided or delayed, and others recommended. Jaw exercises were proscribed and replaced with lower jaw and face pampering, such as facial massage and limiting jaw opening. Chiropractic and osteopathic jaw/ cranial bones manipulation treatment were excluded, including manipulation of cranial bones such as the pterygoid plate region. Electric heat pads (Beurer GmbH) were recommended with low, medium and high settings and an automatic cut off mechanism at 1.5 hours. Heat packs were avoided as they lost heat quickly when compared with electric heat pads and were generally thick enough to detrimentally deflect the mandible and neck. A cold pack was recommended when there was a diagnosis of acute synovitis and/or acute TMD pain. In all other situations heat was recommendedforTMDtoremovelacticacid and associated spasm and pain. The use of low-dose muscle relaxant medication, once or twice weekly, was recommended when extreme pain or debilitating mandibular restriction was encountered. Physiotherapy treatment was often selectively avoided or delayed until the patient had completed formal occlusal splint therapy. There were some exceptions to this ‘general rule’. Patients who were benefiting from prior physiotherapy were encouraged to continue. In addition, patients with acute closed lock disc displacements were recommended intense physiotherapy after the first splint adjustment particularly if a neck condition was compounding the condition. Physiotherapy was strongly recommended following arthrocentesis. Patients with chronic sinusitis often have black bags (venous congestion) under their eyes, post-nasal drip and chronic coughing, painful sinuses and acute/chronic masseter tendonitis under their cheek bones. These painful sinus symptoms often are a result of an allergic hypersensitivity reaction to antigens such as dust mites or dust. Often, in a vain attempt to rid this pain, the patient repetitively clenches, particularly at night, on their upper teeth pushing them against the adjoining sinuses. Chronic clenching often results in masseter and TMJ pain and this sinus condition has been addressed by the author over the last 25 years. A compounding pharmacist is asked to mix a fresh solution of an antiseptic to deliver with steam a benzoin resin/ menthol inhalant. As well, the patient should be encouraged to wear a mask in a dusty environment. Finally, the use of a topical oil intra-nasally, such as olive oil is recommended in the morning before work, to coat delicate dry hypersensitive nasal mucosa as a barrier against antigens and microorganisms found in a dusty or air conditioned environment. The following acceptable adjunctive procedures have been recommended for TMD patients (but these were not used for the 200 cases in the study), with unresolved signs and symptoms following ‘Formal Fully Protective Occlusal Splint Therapy’ (Darveniza 2022) namely: arthrocentesis, mandibular manipulation (Okeson 2007), custom jaw exercisers (Darveniza and Chapman 1985), prefabricated jaw exercisers (TheraBite, Teleflex Medical Europe Ltd, Ireland, UK), local anaesthetic blocks administered by a musculo-skeletal physician and the Botulinum toxin by a neurologist or oral surgeon. Injecting Botulinum directly into the TMJ or lateral pterygoid muscle was excluded. Discussion The ‘Full Counselling’ protocol delivers to the patient written and personally explained instructions by the dentist and dental assistant, as a counselling team. This protocol also targets dentists, so they have a checklist with the correct information required for consistency in a group practice setting. This informs the patient how to operate a splint, with a focus on their unique errant and unprotected mandibular movements (Darveniza 2001). The author has treated TMD patients since 1981 primarily from an occlusal and behavioural point of view and with a focus on head, neck, and facial relaxation adjunctive therapies. This has prevented patients’ from perpetuating their individual occluso-mandibular habits andminimising poor patient outcomes. The evolution of sleep posture analysis since 1992 has addressed the need to help those patients with deep seated sleeping problems. It also has highlighted the importance of mandibular support, when sleeping side on, offered by the contralateral hand positioned flat under the pillow and below the mandible. When the presence of residual symptoms cannot be accounted for, sleep posture needs to be considered along with the use of an electric heat pad. The‘FullyProtectiveOcclusalSplint’was presented by the author at the University of Queensland continuing education handson clinical course in May 1984. The design evolved and now has both quantitative Fig. 24 The top view of this TMD patient undergoing a sleep posture analysis illustrates the patients’ preferred sleeping position was on the front or abdomen. Note the chin has been pushed to the left and this results in the right condyle/disc assembly being located out of the fossa. In this position the patient felt pain/strain in the right trapezius and sternomastoid muscles, and TMJ. The lower photograph illustrates the recommended side sleeping position and the relaxed posture at the end of the analysis. This reveals that the right hand and forearm are located flat under the pillow to support the mandible, TMJ’s, skull and point of the right shoulder. The right shoulder fits beneath the pillow and was slightly cocked to support the head and neck. The top view shows a closed right fist and, in the lower view the recommended sleeping position was a flat or slightly cupped hand. Fists make the body tense and should be avoided during sleep.
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