Pains + Anxiety + Health Habits + Trauma =

Chronic Pain

"PAINS" in head & neck region are complex structures, complex mind body interplay, and develop in unique series causing increase intensity of pain and adaptation of pain system. The only force that can influence body to heal is a team professionals.

How can you hope a doctor selling the latest fad in medicine like botox, ARS, or guru's magic potion could solve your pain problems ? I know you are too busy to mess with this pain demands any more than broken leg, but pain will steal your happiness.

As teen or early 20's we develop pain #1, say it is tension headaches (HA). As we enter college or work force, we develop pain #2 say neck pain. Now as woman with two children-house-career-social-ole yes-husband, we develop pain #3, say restricted opening or atypical toothache. With women's 36 hour day or man's 28 hour day, we reach point when quality of our life is in jeopardy.

The word "PAINS" are typically structural damage or infection or inflammation that is additive until the pain system is reaches an overload of signals.

PAINS

Chronic Overlapping Pain Conditions (COPC):

1. 51 % of people with headaches have one or more of COPC
2. Overlap between headache & painful TMD is considerable
3. Migraine has strong relationship with TMD
4. 18% of TMD patients have fibromyalgia
5. Most COPC have somatic symptom burden, greater psychological stress, and higher pain catastrophizing
6. Most COPC are bidirectional on psychological stressors

HEADACHES:

1. Tension Headaches
2. Migraine

HEAD PAIN:
A source of pain coming from the head area, unilateral or bilateral, moderate-severe, episodic-daily-constant, can be pure Ten HA-migraine or Mix HA, may have symptoms with other special organs like eyes, ears, joint, teeth.

Adolescents with migraines and tension HA have higher emotional liability and lower self-esteem.

Headaches Champions

MIGRAINE HA       =       NEUROLOGIST
TENSION HA   =      OROFACIAL PAIN SPECIALIST MIXED HA = OROFACIAL PAIN & NEUROLOGY

MIXED HEADACHE Management:

• Orofacial pain focus is use of Integrative Tools, not medications
• Orofacial pain reduces inflammation from chewing system
• Orofacial pain must reduce other sources inflammation in head & neck
• Orofacial pain focus is reduce inflammation in chewing system
• Chewing system is major source of inflammation
• Biggest source inflammation is destructive grind/clench
• Newly discovered sources inflammation: hypermobility, chemical sensitivities, sleep apnea
• Neurologist treat migraine HA with Tryptans or CGRP meds

Headache Categories & Prevalence: 1. Tension Headache: 48% females, 38% males 2. Migraine Headache: 18% females, 8% males

Tension Headache:

1. Episodic--frequent--daily
2. Unilateral or bilateral
3. Side head or temples
4. Temple is chewing muscle
5. More frequent women, age 30 to 50
6. Pain Descriptors: Dull, ache, throbbing
7. Contributors: Tension muscles, Grind-Clench, Anxiety, Jaw trauma
8. Pattern: Worse upon awakening, worse day progress

Mixed Headache are mixtures of tension and migraines. They present as whole head headaches or bilateral temple HA. They are moderate to severe. They are mixtures dull-ache with spikes of throbbing pain. They are frequent episodic or daily. They may have mild photo-phono as post headache symptom when headache severe. No aura (no visual effect before onset headache). Most have cervical dysfunction.

Migraines are accumulation multiple source inflammation in head & neck region. Migraines are severe throbbing pounding whole head headaches. Migraine specialist are neurologist.

Orofacial specialist may assist neurologist treating migraine by reducing massive inflammation load coming from chewing system. All headaches reduce frequency, severity, and duration after chewing system orthopedics.

NECK PAIN:

30% to 50% of population have neck inflammation-damage-pain that affects their quality of life.

TRAUMA: Tearing Lateral Ligament TMD:

1. Blows
2. MVA
3. Falls
4. Injury-sports

In 22 of 25 post-whiplash cases, articular disc disorder was diagnosed (tearing lateral ligament TMD)
Weinberg & Lapointe     1987. J Oral Max Surg          45:653

Motor Vehicle Accident: Sudden acceleration deacceleration of condyle will tear lateral ligament of the temporomandibular joint and tear ligaments of cervical region.

WHIPLASH illustration: Showing effect TMD

Whiplash in ER: Did you know Jaw Joint gets damaged as do necks in car accidents. in a study where they took MRI on series of whiplash injuries, 22 out of 25 of the TMD's had disc displacement.

NECK PAIN: A source of Inflammation muscles and joints of neck, special structures in neck, can be unilateral or bilateral, can be Mild-moderate-severe, can be Episodic-daily-constant

TALE TWIN SISTERS: following an motor vehicle accident:

1. Cardiovascular conditioned sister has neck pain for week
2. Decondition sister has neck pain for lifetime

Cervical muscles

1. Pain in cervical system sets up guarding muscle activity in jaw
2. Cervical muscle contraction causes bracing in chewing muscles.
3. Poor posture neck causes reciprocal contraction hyoid then jaw muscles to brace 

Jaw Pain

10% to 15% population suffer from jaw joint pain & dysfunction impairing their chewing system and affecting quality life.

Progression of Disc displacement:

1. Clenching/grinding excessive muscle pull Superior Lateral Pterygoid (SLP)
2. Tension muscles set up variable contraction SLP
3. Pain in neck causes muscle bracing in chew & neck muscle
4. Sudden tearing lateral ligament in MVA, Fall, Blow

Tearing of lateral ligament of disc:

1. Pre-tear: micro tear from tension in muscles and clench/grind
2. Trauma: m: macro tear
3. Post-tear: micro tear from tension in muscles and clench/grind

JAW JOINT-TRAUMA

Sports-Related Injuries & TMD:

1. 11-18% all sports-related injuries were maxillofacial injuries
2. 44-99% of temporomandibular joint (TMD) problems are caused by trauma
3. Risk is dependent on sport played & amount  protection used
   a) female basketball injury rate = 7.5%
   b) female basketball 15 times higher than men’s football
   c) males use more protective equipment (ACPF 37:3,2001)

Certain blows to jaw with right force and direction can tear the lateral ligament to jaw joint

FALL: produces whiplash injuries like tearing to LATERAL LIGAMENT OF TMD DISC

CHEWING SYSTEM DAMAGE:

1. a source of inflammation coming from chewing muscles and joints of TMD
2. Inflammation from tooth, gums, ligaments, nerves of mouth
3. unilateral or bilateral,
4. mild-moderate-severe,
5. episodic-daily-constant,
6. Restricted opening
7. Atypical ear or Atypical toothache
8. Bite changes

Damage joint-disc-lateral ligament relationship:

1. Mild damage = partially displaced disc
2. Moderate damage = complete displaced disc
3. Severe damage = bone on bone=osteoarthritis

RESTRICTED OPENING REFERRAL

1. Restricted opening indicates moderate damage to TMD
2. Moderate damage means completed displaced disc
3. If disc is not recapured timely manner it will remain displaced
4. Urgent referral to orofacial pain specialist increase chance of recapture
5. Chewing system orthopedics is a team of professionals
6. Orthopedic team is patient, biofeedback, physical therapy, and Orofacial Pain Specialist
7. Tension muscles, Grind-Clench, Stress-anxiety, Trauma, Neck pain are major causes
8. Loss space in TMD due disc displacement loads molars causing failed Implants & Crowns

Dental appliances are not effective on moderate damage muscle joint complex of jaw joint. (Biteguard, Nightguard, Anterior Repositioning Splint, LVI appliance, OLMS, NTI -anterior deprogrammer)

A general dentist may treat muscle pain or mild damage TMD (partially displaced disc), but if there is moderate damage to TMD, they need to be refer to orofacial pain specialist for chewing system orthopedics.

Moderate Damage requires team health care professionals:

1. Physical therapist
2. Biofeedback
3. Orofacial pain specialist
4. Patient

Dentist & hygienist choose refer restricted opening to Orofacial Pain Specialist due complex of problem and complexity of joint.

Anesthesilogist with a report of history restricted opening or restricted at time exam, need to refer Orofacial pain specialist to provide healing to TMD so intubation can be provided w/o post operative jaw pain.

ATYPICAL TOOTHACHE

Atypical Toothache= 7 % to 12 % of all toothaches are not pulpal origin

Atypical toothache: HINTS

1. Majority of dental test negative
2. Filling is not close to inside nerve
3. History of sensitivity, discomfort
4. Not progressive pain
5. Adjusted occlusion, root canal, or crown= no benefit
6. NTI or nightguard =benefit

Inside nerve verses outside nerve:

1. If you think tooth pain is associated with pulp tooth refer endodontist.
2. If you think tooth pain is associated w/ outside nerve refer orofacial pain specialist.
3. If you are not sure, refer endodontist. If the endodontist feels it is outside nerve, they will refer orofacial pain.
4. If you not sure inside or outside nerve, refer orofacial pain who acts as diagnostic clearinghouse

For anyone so brave and ego centric to think this is always clear, you need to go to endodontist or orofacial pain specialist office to shadow to learn the art of diagnosis difficult cases and respecting the level difficulty.

Diagnostic tree for atypical toothache

1. Pulp tooth-deep crack
2. Outside nerve-shallow crack
3. Muscle refer
4. Joint loading
5. Trigeminal Ganglion referred
6. Atypical Odontalgia
7. Miscellanous

Atypical Earache

Symptoms Atypical Earache

1. Periodic unilateral earaches
2. No inflammation ear canal
3. Does not respond antibiotic
4. No infection symptoms (fever, malaise)
5. Hearing aid discomfort
6. Tinnitus & Dizziness
7. Hearing test normal
8. Jaw joint connect ear by cartilage & bone

Jaw joint complex is the 2nd most likely cause ear discomfort

Trigeminal Nerve

Neuralgia, Neuritis, Neuroma 5th Cranial Nerve

1. Trigeminal Neuralgia=TN inflammation in cranial root ganglion by arterial irritation
2. Neuroma= trauma nerve causing improper proliferation of nerve ending as healing response
3. Neuritis= viral infection of trigeminal nerve
4. Burning mouth syndrome = tip tongue & palate constant burning feeling

Impulses through damage nerve:

1. abnormal function (grind/clench) cause increasel rate impulses
2. normal function cause impulses
3. damage nerves produce abnormal impulses
4. anxiety nerves connect pain nerves
5. anxiety impulses are pain impulses

Complexity nervous system, pain system and chewing system sets stage for complexity of Orofacial Pain team to manage the annoying-ongoing-relentless-nerve pain.

Orthotic is diagnostic tool for reducing impulses through trigeminal nerve.

SINUS

Discomfort in face associated w/ inflammation in outside nerve of upper tooth near maxillary sinus causing confusion between sinus and tooth causalgia.

Hints/Symptoms:

1. Episodic (comes & goes)
2. Unilateral
3. Pressure/Discomfort in face
4. Antibiotics & Decongestants are no benefit
5. Restorative dentistry is no benefit
6. NTI or nightguard are diagnostic tools

HYOID

HYOID SYSTEM: a source of pain coming from mostly inflammation from hyoid system, includes inflammation from suprahyoid and subhyoid muscles unilateral or bilateral, mild-moderate-severe, episodic-daily-constant,

UPPER RESPIRATORY SYSTEM: Allergies, VIrus/Bacteria, Sensitivities, Airway Mannagement; any source of inflammation coming from the tissues in direct contact with outside world, interaction with lymph tissue and immunity systems sets up inflammation,

Swallowing is hint of hyoid system dysfunction. Airway restriction is cause of hyoid dysfunction Odd symptoms associated w/ hyoid accompanies many TMD cases w/ little science for diagnostic efforts.

Forward position of hyoid system & mandible is set up by small air pipe. The positioning of the hyoid system forward drags the tongue out of the air pipe and the muscle that must do work is Lateral Pterygoid that displaces disc in TMD. Make matters worse for displace disc some dentist are using ARS appliances on purpose to open airway. Even if this looks good for airway, it will increase the number displaced disc or increasing the TMD in world.

Some patients brace the mandible in forward position to pull the tongue out airway when they have a severe airway problem. This is adaptation required for survival, but it is not an improvement on health of joint. Another form of parafunction and parafunciton damage the jaw joint disc complex.

Look to future of science in discovering many of these observations that are more clinical, but these are seeds to research direction in future.