The Patient with Chronic Unresolved Head, Neck and Face Pain
"Once we know the WHAT, the WHERE, and the WHY of a patient's complaint we are in a position of planning a rational and effective therapy - and without that information we simply have to guess and hope. Once we have that information we make our differential diagnosis, which is the first step in rational therapy." ~ Weldon Bell
More than 50% of all visits to the family physician each year are for the treatment of some variety of head or back pain. In addition, 43% of all "healthy" patients suffer from some type of head or back pain and 11% have both. Quite often these visits result in the referral of these patients to one or more groups of medical specialists in search of a cause for their pain. After careful examination of the patient by the specialist these may still be negative findings and diagnosis becomes difficult, if not impossible. Unfortunately, it is advised by his doctor to seek a psychiatric consult in order to rule out a psychosomatic etiology to the pain, or advice is given that he or she will "simply have to learn to live with their pain and cope with it as best they can".
If you are currently treating patients who are suffering from chronic headaches, neck pain, otalgias, vertigo, tinnitus, shoulder pain and stiffness, and the etiology of their condition remains baffling after all routine tests have been completed, perhaps you are being faced with the clinical manifestations of:
Temporomandibular Joint Dysfunction Syndrome or Myofascial Pain Syndrome
Myofascial Pain Syndrome and Temporomandibular Joint Dysfunction Syndrome are distinct and separate clinical entities, although the two terms are often used synonymously. Myofascial Pain Syndrome can occur in any muscle group throughout the body. However, when they occur in the cervical and stomatognathic musculature the symptomatology can mimic that of a Temporomandibular Joint Dysfunction Syndrome.
MYOFASCIAL PAIN SYNDROMES: MPD syndromes are recognized medical entities which can affect single muscles or large muscles groups anywhere in the body. Myofascial Pain Syndromes affecting the stomagnathic musculature are unrelated to occlusal discrepancies. When myofascial pain causes the development of a reflex myospasm, the e term Myofascial Pain Dysfunction then applies. As stated in the July 1978 issue of the New England Journal of Medicine, MPD syndromes are a psycho physiologic condition primarily caused by tension habits that create spasm of the masticator musculature with the resultant development of an occlusal disharmony caused by the myospasm. The following diagram illustrates the manner in which anxiety and tension can cause pain, which in turn, can cause myospasm and the subsequent development of additional tension and anxiety...a vicious cycle.
TEMPOROMANDIBULAR JOINT SYNDROMES: TMJ Syndromes have their primary etiology in the temporomandibular joint mechanism itself. The actual joint pathology may involve the ligaments, capsule (Meniscus) or osseous structures and can result from either extrinsic or intrinsic trauma. Extrinsic injury can result from a blow to the face, jaw or temporomandibular joint complex. Whiplash is another very common cause of extrinsically induced trauma to the TMJ. Direct traumatic injuries to the face, jaw or joint complex can result in inflammation, fracture, hemarthrosis and ankylosis of the joint. In cases of whiplash injury, the temporomandibular joint condyle is "pulled" into a non-physiologic relationship with the glenoid fossa of the temoporal bone by the resulting myospasm. If undiagnosed or untreated, which is unfortunately most commonly the case, the long term presence of this chronic condylar displacement may lead to the development of degenerative osteoarthritis of the temporomandibular joint mechanism. Intrinsic trauma to the temporomandibular joint complex may be caused by the presence of occlusal or craniomandibular discrepancies. Such discrepancies may result from drifting of the dentition (due to failure to replace teeth following extraction), inadequate or unfinished orthodontic therapy or the placement of iatrogenic dental restorations.
SYMPTOMS OF TMJ AND MPD SYNDROMES: It is important to realize that in excess of sixty percent of all TMJ and MPD patients do not recover from their illness simply due to the fact that the patient is not properly diagnosed. This unfortunate fact holds true because most physicians and other health professionals fail to recognize the manifold symptoms of TMJ and MPD Syndromes as being related to a dysfunction of the stomatognathic musculature or to the presence of a non-physiologic condyle-fossa relationship. The patients also fail to bring their symptoms to the attention of a dentist because they cannot rationalize these chronic pain symptoms as being associated with a dysfunction of their occlusion or jaws. It is important to emphasize, however, that once properly diagnosed and treated; the prognosis for a full recovery becomes very favorable. In fact, the current statistics indicate that 90% of all treated patients recover fully and 50% experience a significant decrease in symptoms. Quite a "batting average"!
The following chart outlines the chief complaints presented by both the TMJ and MPD patient and further substantiates the need for differential diagnosis of these two clinical entities:
TMJ MPD
Headaches X X
Light headedness X X
Vertigo X X
Buzzing or other sounds in the ears X X
Fullness in the ears and /or sinuses X X
Backaches (upper or lower) X X
Neckaches X X
Pain on Mandibular movement
(opening, chewing) X X
Clicking sounds from the TM joint X X
Pain in the facial muscles X X
Pain from the TM joint X X
Referred odontalgia X X
Pharyngeal pain
Pain in the eyes or visual disturbances X X
Chronic fatigue X X
Pain on palpation of the joint through
The external auditory meatus X X
The following are the clinical findings most commonly observed in the TMJ and MPD patient populations:
Radiographic changes in the TM joint X ---
Related to occlusal discrepancies X ---
Primary etiology is stress syndrome --- X
Thus: If the patient is classified as suffering from a "TMJ Dysfunction," radiographic changes and occlusal discrepancies must be documented. Such radiographic and occlusal pathology is best interpreted by a dentist knowledgeable in the science of TMJ Dysfunction.
TREATMENT
The treatment and management of the TMJ and MPD patients must first begin with a proper diagnosis. Once diagnosed, however, both the oral and muscular components of these multi-causal syndromes must be managed.
Treatment of these syndromes is approached in a multi-disciplinary manner, utilizing both orthopedic and neuromuscular physiotherapeutic treatment regimens, in addition to adjunctive pharmacological and phychotherapeyutic treatment.
The muscular component of these syndromes (myospasm of the head and neck) is treated with muscle physiotherapy consisting of transcutaneous electroneural stimulation (T.E.N.S.), electrogalvanic stimulation, cryotherapy and counter-irritant sprays, ultrasound, moist heat myotherapy, muscle injections of local anesthetics into trigger areas and muscle exercise therapy.
The oral component of these syndromes is effectively managed with the aid of one of several designs of oral orthopaedic "TMJ" appliances. These appliances not only serve to othopaedically reposition bones into a proper relationship with each other, thus improving the function of the joint, but also serve as neuromuscular appliances by maintaining the muscles of mastication in their proper resting length from origin to insertion.
In addition to neuromuscular physiotherapy and orthopaedic appliance therapy, the pharmacologic management of the TMJ and MPD patient must also be emphasized. Patients, who are often depressed, exhibit sleep disorders and have lowered pain thresholds, require pharmacological therapy to manage pain and stress response. Gregg states that the cyclical nature of MPD episodes would tend to suggest a malfunction or perhaps exhaustion of the endorphin-serotonin response to pain and stress stimuli. Serotonin is the likely biochemical common denominator which accounts for many of the related symptoms of musculoskeletal complaints in myofascial pain patients.
Psychotherapeutic treatment modalities which may be utilized in the treatment of TMJ and MPD patients are generally geared to stress reduction and behavior modification. Relaxation training and/or biofeedback may be utilized to supplement stress response reduction.
It is important to note that in addition to Temporomandibular Joint Dysfunction and Myofascial Pain Dysfunction Syndromes, Temporomandibular Joint Arthritis is another major cause of unresolved and undiagnosed head and neck pain. Other common symptoms of TMJ arthritis include retro-orbital pain radiating to the temporal region and down the back of the neck, otalgias, loss of hearing, sinus congestion, vertigo, tinnitus and paresthisia of the ear, face, neck, arms and fingers. TMJ arthritis is often effectively treated with the fabrication and insertion of oral orthopaedic appliances, myotherapy to the spastic musculature and subsequent occlusal modification.
SUMMARY
In summary, the following points must be emphasized:
1. Temporomandibular Joint Dysfunction Syndromes and Myofascial Pain Syndromes are separate and different clinical entities, although the terms are often used synonymously. TMJ dysfunction syndromes have their etiology in either an intrinsic joint pathology, or the presence of a specific occlusal mal-relationship. Myofascial pain trauma and can affect any muscle or muscle group in the body. Involvement of the masticatory muscles results in Myofascial Pain Dysfunction Syndrome.
2. Myofascial pain dysfunction syndromes and temporomandibular joint dysfunction syndromes are amount the most commonly seen and misdiagnosed syndromes consulted for by the psychiatric, orthopaedic, and neurologic medical communities.
3. Myofascial pain syndromes commonly spread from the cervical to the stomatognathic musculature. Stomatognathic muscle spasm is very effectively treated with an intraoral orthopaedic repositioning appliance. this appliance not only serves as a neuromuscular appliance by maintaining the muscles of the mastication in their proper resting length from origin to insertion, but also to orthopaedically re-position bones into proper relationship with each other, thus improving function of the joint. Neuromuscular physiotherapy techniques, such as T.E.N.S., high voltage electrogalvanic stimulation, ultrasound, moist heat myotherapy, cryotherapy and trigger area injections are valuable modes of therapy for treating Myofascial Pain anywhere in the body, as well as for Temporomandibular Joint Dysfunctions.
Pharmacological therapy plays an important part in the overall treatment of TMJ and MPD in cases where emotional states, such as stress, anxiety and depression are observed, as is often the case. Psychological and pharmacological management of these disorders, though rarely considered, are integral aspects of treatment.
4. A small percentage of all MPD patients may require a permanent alteration of the cranio-mandibular relationship in order to be rendered asymptomatic. Thus, TMJ and MPD patients can best be treated and effectively managed by a dentist trained in the utilization of the most current and recognized treatment modalities, such as have been previously mentioned, while acting within the scope of his license.
