Bringing Patients Comfort During Lengthy Dental Procedures

Prior to going to dental school many years ago, I worked as a chairside dental assistant for an oral surgeon. One of my primary responsibilities was to support the mandible with upward pressure of my fist against a bite block while the surgeon worked to extract mandibular third molars. Meanwhile, another assistant was responsible for holding the airway open by pulling the jaw forward with her fingers wrapped bilaterally around the rami of the mandible. Is there any wonder why many of our extraction patients experienced post-op bruising in areas of the jaw that were not even treated?

Unfortunately, today as a general dentist, I find myself asking my assistant to support the lower jaw with her fist during lengthy restorative procedures. How strong does your assistant have to be in order to apply the correct amount of support? Who knows? Thankfully, if I’m using something like an IsoDry that suctions and serves as a bite block, she can dedicate that one fist – at least intermittently – to support the patient’s jaw. However, some patients still develop jaw pain and soreness – even occasional locking of the jaw – during lengthy dental procedures.¹

More than 50 percent of TMD cases can trace their onset to trauma, with the majority of these attributed to the mouth being opened too wide for too long, or with too much applied force, during dental procedures.² One paper has even attributed almost 25 percent of temporomandibular disorders to third molar extractions.³ We also know that when a patient is asked to keep their mouth open for lengthy periods even with breaks, the muscles of mastication can fatigue, and the ligaments of the TMJs can stretch. According to one study, when lengthy dental procedures – like endodontic treatment or full-mouth reconstruction therapy – are performed, there is a 400 percent greater chance of a patient developing a painful temporomandibular disorder?⁴

While we have many tools available today to assist in keeping the mouth open during treatment (e.g., mouth props, bite blocks, rubber dams, IsoLite/Isodry, DryShield, etc.), the only tools we have had to stabilize the jaw and resist downward force, or to assist jaw elevator muscles, involves five fingers that could be more efficient performing any number of the necessary tasks of a dental assistant. The compromises that result from the assistant supporting the mandible have been accepted as standard risks: lost productivity due to longer appointments to allow for frequent breaks, compromised chairside manner due to the frequent commands and instructions to open or tilt the chin up, and frustrated or disgruntled appointments due to fatigue and jaw discomfort that may force termination of treatment.

There is a device now on the market that minimizes these compromises,⁵ especially when used in conjunction with a bite block or bite block/suction device. The Restful Jaw was developed by Dr. Eric Schiffman, the director of the Division of TMD and Orofacial Pain at the University of Minnesota College of Dentistry. While initially skeptical, I decided to purchase the device and try it with my patients. Prior to using the device, I had planned to only use it for extractions. However, I found that those first patients who experienced it loved it so much that I now use it for any procedure longer than 15 minutes, including CEREC crown preps and bonding procedures, extractions, scaling/root planing, etc.

It is a relatively simple device that rests on the chest and straps behind the arms, with a support arm and comfortable chin pillow that provides firm stabilization of the mandible. While the manufacturer reports that it takes less than two minutes to put on the patient, my experience has been that it is MUCH less than two minutes. When the patient sits down, my assistant attaches the device with the chin rest disengaged and then places the patient napkin over top of it. When I sit down to begin treatment, I simply reach under the patient napkin, depress the release button, and slide the support arm up to meet the patient’s chin where it is in my desired treatment position and then release the button. I then ask the patient to tell me when the chin pillow is comfortable (it usually literally positions itself to adapt to the patient’s chin) and tighten the adjustment screw. This whole process takes less than 45 seconds. When combined with my IsoDry system, the patient’s mandible is completely supported and incredibly stable. Using my video microscope and high magnification is much more comfortable, and procedures are completed much more quickly and efficiently because breaks are not typically needed.  This experience is consistent with the reports I read in the literature. My patients have told me that it is “extremely comfortable” and that it “feels like the jaw is sitting in a couch.” In fact, the other day I actually received my first hug in nearly 20 years after an extraction of a mandibular first molar – it was a tough surgical extraction!

The Restful Jaw and IsoDry combine for stabilization and comfort of the jaw and make life for the dentist easy. (For proper infection control, the patient napkin would be placed over the Restful Jaw device.)

I have no financial interest in the Restful Jaw. However, since many dentists, especially those who train at Spear, do complex procedures requiring lengthy appointments, I sincerely believe that due consideration should be given to utilizing the device; more on the device can be found at www.restfuljaw.com. The Restful Jaw is the newest in a continually growing list of items that I cannot practice dentistry without – Isolite, loupes, high speed electric hand-piece, headlight … and the Restful Jaw is an excellent addition.

(Click this link for more articles by Dr. Kevin Huff.)

Kevin D. Huff, DDS, Spear Moderator and Contributing Author - www.doctorhuff.net

References

1. Sahebi, S, Moazami, F, Afsa, M, Nabavizade, MR. Effect of lengthy root canal therapy sessions on temporomandibular joint and masticatory muscles. Journal of Dental Research, Dental Clinics, Dental Prospects. 2010;4(3):95–97.

2. Fricton, JR, Kroening, R, Haley, D, Siegert, R. Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients. Oral Surgery, Oral Medicine, Oral Pathology. 1985;60(6):615–623.

3. Huang, GJ, Rue, TC. Third-molar extraction as a risk factor for temporomandibular disorder. The Journal of the American Dental Association. 2006;137(11):1547–1554.

4. Ohrbach, R, Sharma S, Wactawski-Wende J, Bair E, Fillingim R, Greenspan J, Diatchenko L, Maixner W, Slade G. Trauma and TMD Onset: Descriptive Characteristics from the OPPERA Study. IADR 2015, Boston, MA. Abstract.

5. Fernandes, P, Velly, AM, Anderson, GC. A randomized controlled clinical trial evaluating the effectiveness of an external mandibular support device during dental care for patients with temporomandibular disorders. General Dentistry. 2013;61(6):26–31.