Faculty Profile

Dr. Elizabeth Hatfield: All in on the quest to treat orofacial pain and TMD

Diagnosing and treating patients with widely varying symptoms of orofacial pain and temporomandibular joint disorder is a continual challenge that appeals to Dr. Liz Hatfield.

Many of her patients have experienced chronic pain for decades, so finding an effective treatment is immensely rewarding. On a broader level, she is contributing in numerous other ways to this field because of the educational role she leads on a daily basis.

Hatfield is a clinical assistant professor in the Department of Oral and Maxillofacial Surgery/Hospital Dentistry and is Director of the Temporomandibular Joint Disorder (TMD) and Orofacial Pain Residency Program. She leads residents through a clinical care and seminar program that includes Neurology, Headache and Neuropathic Pain, Pediatric and Adult Rheumatology, Physical Medicine and Rehabilitation, Movement Disorder, Otolaryngology, Anesthesia Pain, Sleep Medicine, and Oral and Maxillofacial Surgery. She also teaches at the dental school.

The two-year residency program is relatively new. Hatfield was the first resident, receiving her certificate in 2020, the same year the American Dental Association recognized orofacial pain (OFP) as the profession’s 12th specialty. Hatfield became interested in the field during her General Practice Residency (GPR) at U-M, which she finished in 2018 after earning her DDS from the U-M School of Dentistry in 2017.

During her GPR, a two-week OFP rotation with Dr. Lawrence Ashman drew Hatfield away from her general dentistry plans and into the OFP residency. The more she learned about how the body manifests pain and the difficulties of diagnosis in many cases, the more she was convinced that this was the kind of clinical care she wanted to pursue. The research project she did during her residency had the distinction of being the cover story in the December 2019 issue of the Journal of the American Dental Association. Hatfield was the lead author of a study reviewing medical literature on the efficacy of low doses of naltrexone in the management of chronic pain conditions, particularly orofacial pain.

The title of a Continuing Education course she has presented in recent years summarizes the challenge for the OFP clinician: “My Face Hurts, Can You Help Me? Diagnosis and Management of TMD & Orofacial Pain.”

OFP is pain that is perceived in the face or oral cavity and caused from diseases or disorders there, though the pain can sometimes be caused by more-distant parts of the body. It can also be dysfunction of the nervous system, and often OFP is related to disorders of the hinge-like temporomandibular joint (TMJ) and related muscles that connects a person’s lower jaw to their skull. Treatment is wideranging, from physical therapy, bite splints and other oral appliances, medication and injections all the way up to complex surgery including TMJ replacement.

Hatfield said the U-M residency program emphasizes non-surgical management, starting with conservative treatment options and minimally invasive procedures rather than going too quickly to surgical options. Hatfield and two oral and maxillofacial surgeons, Drs. Mohamed Hakim and Ron Aronovich, have been collaborating on new protocols for the best ways to transition patients from their initial treatment to minimally invasive surgery and back to their OFP clinician. It’s an effort to do a better job of focusing on what fits each patient best.

The U-M OFP clinicians tend to see patients who have “chronic refractory pain that has been there for years and years and years,” Hatfield said. Planning treatment involves a lot of listening to patients explain their pain, its origins, how it has changed and many other “little puzzle pieces.”

“The thing that is tough about pain is that it’s not visible,” Hatfield said. She recalls one patient with longstanding headaches who was frustrated because well-meaning friends and relatives would regularly ask how she was feeling. “It gets old telling people I hurt everyday,” the patient told Hatfield. “People don’t want to hear that because nothing looks wrong with you. You’re sitting there and you look fine and you are at dinner with everyone, so you must be OK.”

As if being in constant physical pain isn’t bad enough, patients often experience emotional pain as well when family and friends are insensitive about their condition. That sort of stigmatization is common, Hatfield said. She recalls counseling a patient with severe muscular pain who was distraught because her life partner was unsympathetic and it was causing their relationship to fall apart. Once an effective treatment was found in Botox injections, which significantly reduced the pain, the patient’s attitude and outlook were transformed. “Now, when she came back for follow-ups, her pain is under control, she is happy, they are happy, she has her life back,” Hatfield said. “Every time I get to see her, it makes my day.”

Medication management is important in the field as is coordinating interdisciplinary care with healthcare colleagues in areas such as neurology, rheumatology, physical therapy, behavioral management and oral surgery. “Oftentimes, it’s a multi-modal treatment that we have to come at from different angles,” she says.

Beyond her satisfaction in treating patients and leading the educational program for residents, Hatfield said another important aspect of her job is looking at big-picture ways to strengthen the relatively new dental specialty of OFP, not only at U-M but on a broader national and world level. One way she does that is in helping organize a national online Continuing Education course called Interprofessional Case Studies in Headache and Orofacial Pain. Originally started by Tufts University, the course is held via Zoom four to six times a year, usually on Saturdays. It draws from 350-500 OFP residents, faculty and clinicians, mostly from around the country but some log in from around the world. The sessions are designed for residents to present case studies and research, with discussion from leading experts and class participants. The idea is to efficiently spread evidence-based research and experience to a wider audience of OFP providers, as well as the general dental and medical communities, to enhance interprofessional understanding and collaboration for the specialty.

“I like academics because there is a big opportunity for educating our next generation and making an impact in terms of patient care,” Hatfield said. “We’re in a great space at Michigan for establishing this as a center for excellence in orofacial pain. That’s what I really want to do through resident education and with clinical faculty who are interdisciplinary, is to contribute meaningfully to evidence-based research. I think this is the right environment for it.”

“There is a lot of non-evidence-based orofacial pain care happening in the state, in the country, in the world. Patients suffer because of it because they don’t know the questions to ask. It is the thing that keeps me up at night. So we try to advocate and meet patients where they are at. I love the individual patient care, but thinking about it on a bigger scale is really important. Making sure that we are not taking advantage of a vulnerable population, that we are trying to provide better access, and part of that is the resident education. That’s the goal, the big picture, and that is really exciting.”