Volume 7 • 2020 • Issue 5

 Symptomatic The first thing we recommend for patients with symptomatic clicking joints is avoidance. It’s important to stop activities that cause clicking, such as eating hard or chewy food. Patients should also avoid cheek biting and daytime clenching, and work to lubricate the jaw by performing a hinge exercise (p. 28). In my practice, I often prescribe Nabumatone, Celebrex or Vimovo. They are excellent medications that are user friendly and reduce pain nicely. When recommending Ibuprofen, keep in mind that it needs to be taken more frequently, which can reduce patient compliance and increase the risk of GI upset. When patients remain very symptomatic, I may mix acetaminophen (e.g., Tylenol) or Tylenol with Codeine. But dentists prescribing these must ensure they complete drug‑to‑drug interaction analysis and confirm there are no medical conditions that would prevent or contraindicate the use of this drug. Once it is confirmed that a patient can take a steroid anti-inflammatory drug, I typically prescribe Dexamethasone 2mg twice daily for 3-4 days, then once daily for 3 days.   Asymptomatic Most patients with clicking jaws are asymptomatic. When a patient comes in for a cleaning, you may notice their jaw clicks when they open their mouth or speak. The patient may also ask why their jaw clicks but does not hurt. In these cases, I offer patient education in the form of avoidance and ask the patient to reduce the number of clicks to 5 or fewer each day. I recommend 5 or fewer, and often a patient laughs but that’s okay. I know they’re going to sometimes click more than five times per day. But just having an awareness if they’re eating an apple, for example, can stop them from trying to get their whole face around the fruit. We want to stop an asymptomatic click from becoming a disc displacement without reduction. Patients will often say, “My jaw used to click all the time and then I was hit in the face,” or, “I was biting into something and all of a sudden now my jaw doesn’t click anymore. Now I have exquisite pain and I can only open halfway.” The jaw has stopped clicking beca us e the disc is no longer reducing. Disc Displacement Without Reduction When the disc no longer reduces, it is because the ligaments have stretched so much the disc no longer snaps back into place. This is disc displacement without reduction. In this case, the stretched ligaments are sensitive and the condyle is in contact with the posterior band of tissue full-time. Now, the patient’s mandibular range of motion is limited and they will often only be able to open 25-35 mm. First, dentists must take time to reassure the patient. Disc displacement without reduction typically produce panic, anxiety, stress, and pain. Reassuring your patient that this is temporary is important. For patients in the acute phase—one to three weeks after displacement has occurred—I will often suggest an injection of local anesthetic and steroid into the joint to try and mobilize the jaw and regain their range of motion. For treating pain without an injection, NSAIDs like Nabumatone, Celebrex, Ibuprofen are great. Sometimes Tylenol, with or without Codeine/Tramadol is warranted. Steroids are common, especially if a patient doesn’t want an injection, I will give a steroid anti-inflammatory drug and then work on regaining the patient’s range of motion. Patients must also apply ice to reduce their symptoms and eat soft food for a while. Often, I will give joint injections for patients in the acute phase (Fig. 1) . There are two medications that are typically used for joint injections: 1.  Hyaluronic acid 2.  Cortical Steroid (with local anesthetic) Hyaluronic acid injections can be given every three to six months and can be used for painful clicking joints. But this is a joint lubricant with the viscosity of honey and it can be uncomfortable. To make it more comfortable for the Most patients with clicking jaws are asymptomatic. When a patient comes in for a cleaning, you may notice their jaw clicks when they open their mouth or speak. The patient may also ask why their jaw clicks but does not hurt. S upporting Y our P ractice 27 Issue 5 | 2020 |