Intra-Oral TMJ Massage and Covid-19
Disclaimer: The tips in this article should not be seen as authorized protocol. These are simply my own thoughts and ideas. You should consult your regulatory college or association if you need more guidance.
As we’re all gearing up to go back to work here in Canada, many RMTs have questions about PPE and procedures. A question I’ve had is about intra-oral TMJ work. This is a technique I use quite frequently as I love treating the jaw and have received extra training in this area and published a case study on massage and TMJ symptoms.
In my training I was always told to use medical gloves but I was never told much more than that aside from avoiding latex if someone has an allergy.
I know the Covid-19 PPE requirements for RMTs across Canada varies. I’m in Alberta with the MTAA and we are not required to wear gloves for general massage treatments. If you are wearing gloves for the duration of the massage, you should change them prior to intra-oral work.
I’ve seen some therapists voice their concerns about working inside the mouth at this time because we all know that the virus can spread through saliva. I think most of the concerns were about the therapist being infected by the patient; however, if we wear gloves and dispose of them properly, and wash our hands, I think that risk is reduced. The primary concern I have is about introducing the virus into the mouth of the patient. We have all been told to avoid touching our faces, so to me it seems pretty risky to allow someone ELSE to put their hand inside our mouth, even with a glove.
So what do we do? I know some therapists are going to avoid working intra-orally for the time being. That’s an option. I just don’t know if that’s a viable option for me personally as it is a technique I use frequently.
My main worry is that there are contaminants on RMTs hands when they reach into a standard box of gloves, because this is usually done mid-way through the treatment, after they have touched doorknobs, the lotion pump, and the client. Are you touching only the edge of the glove or are you touching the finger portion that goes into their mouth? Are you accidentally touching another glove in the box that will be used by the next client? Where are you storing the box? If it is out in the open, could someone sneeze nearby and get infected droplets on the gloves that are exposed at the top of the box?
So what’s the solution to this?
You should wash your hands right before donning gloves and right after taking them off. Please note that using hand sanitizer if your hands are oily is not recommended[1]. You should use soap and water.
Take your gloves off properly so you are not contacting any saliva.
Your gloves should be as clean as possible. Some ideas:
You could use individually wrapped sterile gloves; however, I’ve been having a hard time sourcing these.
You could use hand sanitizer on the gloves after you don them. I have read mixed things about this. Some sources say there is a risk of the hand sanitizer degrading the material causing micro pinholes[2]. Other sources say there is no risk to this[3][4].
You could keep your box of gloves in a drawer or cupboard so they’re not exposed to droplets from anyone in the room coughing, sneezing, or talking.
You could “pre-package” sets of gloves in ziplock bags. If you do this, you should have clean hands and be wearing a mask while packaging.
In addition to proper glove protocol for intra-oral techniques, you may want to consider eyewear if your province/association/college doesn’t already require it. I know the MTAA has stated that if you are conducting intra oral treatments you may want to wear protective eyewear or a face shield as added protection.
If you have any thoughts on this or other resources, I’d love to hear from you!
Good luck to all my massage colleagues at this difficult time. You’ve got this!
Post Note - June 8, 2020
After posting this article, I received some feedback and ideas from readers that I wanted to share.
To avoid having to leave the treatment room to go wash your hands again mid-treatment, you can use this idea:
When you enter after washing your hands at the start of the treatment, take the gloves out by the wrist and set them aside on a clean towel until ready for use.
Another reader suggested how to prepare your TMJ tools in the event that you use more than just gloves. First, she labels which appointments involve TMJ treatment so she can gather her supplies ahead of time. Before the massage treatment (and with clean hands), she places a tissue, 2 gloves, tongue depressor, alcohol wipe and a disposable measuring tool in a sanitized container and keeps it in the massage room. Again, be sure to clean your hands prior to using the tools.
References
Hands washing vs. Hand sanitizer https://www.cdc.gov/handwashing/pdf/hand-sanitizer-factsheet.pdf?fbclid=IwAR2xqgCbuTM66fdNVuSR2xXDXcHcPH7ZjIDzQvCZwMehSOs4AMZa8ARwvb8
States that alcohol-based hand sanitizers may degrade vinyl gloves. https://www.fda.gov/medical-devices/letters-health-care-providers/medical-glove-conservation-strategies-letter-health-care-providers
Testing of 50 latex and nitrile gloves and hand sanitizer. All intact. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5700156/
Testing of nitrile gloves and hand sanitizer. No significant reduction in physical properties https://swsafety.com/technical-report-hand-sanitizer-nitrile-gloves
