June 7, 2021
by David J. Psutka, DDS, FRCD(C)
Oral and maxillofacial surgeons and, indeed, all of the dental profession have been living with the COVID-19 pandemic for over sixteen months. The first few months were particularly difficult. Oral and maxillofacial surgical care, and dental care in general, was limited to emergency management only. Despite lockdown and severe restrictions, the ethical commitment in our profession resulted in the continued provision of urgent and emergent care to our patients in private clinics and hospitals. Diagnosis and care were often rendered through virtual contacts. Despite this, many oral problems had delays in definitive management. The profession saw more infection cases requiring surgical management. The incidence of fractured teeth rose. Damaged teeth that could have been salvaged with restoration ultimately ended up needing extraction. Ironically, the incidence of facial fractures and, in particular, jaw fractures was reduced. It has been opined that the lockdown of restaurants and bars and the needs for social distancing reduced the overall incidence of interpersonal conflict and the resultant trauma.
The increased incidence in tooth fracture is thought to be related to an increase in the prevalence of bruxism and parafunction as a reflection in the overall increase in anxiety, stress, and depression. The fear of serious illness, economic uncertainty and social isolation associated with this pandemic cause psychological responses that vary depending on the individual vulnerability. Given the importance of psychosocial factors in the development and maintenance of TMDs, it is not surprising that the prevalence and severity of TMDs has increased during this pandemic, especially in those who suffer from masticatory muscle disorders.
Practitioners who care for patients with TMDs identify risk factors, initiating factors, and perpetuating factors in their efforts to understand the etiology of the condition in each patient’s case. A poor response to management strategies necessitates identification of and management of perpetuating factors. The most common initiating and perpetuating factors in functional TMDs (internal derangements, osteoarthritis, masticatory myalgias, and, to a lesser extent, mandibular dislocation) are bruxism and parafunctional jaw activities. Parafunction delivers sustained compressive loads to the articular surfaces of the TMJs, which has a deleterious effect on the adaptive biology necessary for joint health. The sustained work performed by the muscles of mastication initiates and perpetuates post-exercise muscle pain in cases of both local primary, regional primary, and secondary myalgias. Increased sympathetic nervous system activity in the face of sustained anxiety and fear can worsen muscle vasoconstriction.
Sleep and awake bruxism, clenching, and other parafunctional activities are poorly understood. While stress is not believed to be a primary cause of this activity, it is generally accepted that stress and anxiety is an enhancer of parafunctional activity. This is evident empirically to those of us who see TMD patients in our practices. Simply, there are more patients who have more pain. Many patients who have been managed with simple measures have experienced relapses during the pandemic. One recent study showed that the coronavirus pandemic caused significant adverse effects on the psycho-emotional status of both Israeli and Polish populations, resulting in the intensification of bruxism and TMD symptoms. Specialists at John Hopkins University have also noted that open mouth breathing, seen in people struggling to breathe during acute phases of COVID-19 infection, can be another type of initiating factor (joint hyperextension, strain) in patients who experience TMJ pain during and after the active infection.
The COVID-19 pandemic has also had an indirect impact on the care for patients advised to undergo in-hospital surgical care for their TMDs. Surgical procedures performed in-hospital for both structural and functional temporomandibular disorders include: TMJ arthroscopic surgery, open arthrotomy and TMJ total joint reconstruction. Efforts to ensure access to necessary hospital-based resources for the care of pandemic victims has resulted in the repurposing and redeployment of hospital staff. There have been significant reductions in available hospital operating room time for all surgical disciplines. Waiting lists, including those for patients needing TMJ surgery continue to grow.
Oral and maxillofacial surgeons, and other dentists who provide care for patients with TMD, have had to respond to the increased needs for these patients. Virtual assessments or teledentistry have increased access. TMD teledentistry is a very effective tool as Dr. Bruce Pynn and I have facilitated virtual assessments and follow-ups for TMJ surgical patients who live in Northwestern Ontario over the past decade. The use of anti-inflammatory medication and muscle relaxant medication like Cyclobenzaprine can be very helpful in managing the arthralgia and myalgia seen in patients with increased bruxism.
Oral and Maxillofacial surgeons increasingly rely on management tactics that do not require hospital operating rooms. There are also minimally invasive surgical procedures that can be performed in the oral and maxillofacial surgery office under sedation or general anesthesia. The use of local anaesthetic for trigger point injections and Botox injected in the muscles of mastication can be very useful in managing persistent resistant myalgia. Intra-articular TMJ injections are useful in managing internal derangements and osteoarthritis. Injectable substances include corticosteroids, hyaluronic acid, and platelet-rich growth factors. Arthrocentesis washes out painful cytokines and can unlock anchored discs. This can be very useful in managing internal derangements and osteoarthritis. Recent publications have shown that the combination of arthrocentesis and the injection of autogenous platelet-rich growth factors is more effective than either modality by themselves.
Dentistry and oral and maxillofacial surgeons will likely have to contend with the dental version of “Long Covid” after the end of the pandemic. Damaged and lost teeth, degeneration of the articular surfaces of the TMJs, centrally mediated chronic and neuropathic pain are some of the ongoing problems likely to affect our patients and challenge our profession. The ethical and caring nature of our profession combined with ever improving evidence based, scientifically sound management strategies will help us all in moving past the pandemic.
About the Author
David J. Psutka, Assistant Professor, Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Toronto. Senior Surgeon, Mount Sinai Hospital Centre of Excellence for Advanced TMJ Reconstructive Surgery. Co-director, University of Toronto Fellowship Program in Advanced TMJ and Orthognathic Surgery. Private Practice, Fountain View Oral, Facial and Implant Surgery, Mississauga.
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