Chronic Orofacial Pain Peter A. Foreman, DDS
Disclosure
Nothing to disclose
Learning Objectives Recognize that myofascial pain and dysfunction (MPD) can present as TMD and other head and neck pains Recognize that convergence of cranial and cervical nerves contribute to referred myofascial/orofacial pain and TMD Describe how orofacial neuropathies may be initiated by surgery or endodontia
Chronic Orofacial Pain
or . . . . staying out of trouble?
Someone who didn’t stay out of trouble
Chronic Orofacial Pain
 includes TMD, TMJD, odontalgias, other neuropathies (TGN, PHN), headache, etc
Today’s Topic: TMD (vs TMJD)
TM disorders (TMD) are common. They may co-exist with but rarely involve the TM joint
Learning Objectives Myofascial pain and dysfunction (MPD) is a cause of many common pains, including TMD and other persistent orofacial and head and neck pains Myofascial trigger points (TrPs) often accompany other conditions and can be readily identified. If not considered, wrong or harmful treatments may result Simple tests for TMD and other orofacial pains due to TrPs will be discussed today, including examples
Rules for Success in Chronic Pain
DIAGNOSIS DIAGNOSIS DIAGNOSIS
No Diagnosis = No Prognosis Richard Kroening, MD Director, Pain Management Center UCLA School of Medicine
Orofacial Pains of Non-Dental Origin The site of the pain is not always the source of the pain (referred pain) Radiographs show hard tissues - teeth, jaws, sinuses and TMJ’s. They do not show muscles, which may be the major source of the pain Even if pathology is present, others with similar signs may not always be suffering from pain
Common Responses by Dentists to Persistent Orofacial Pains That leaky filling needs replacement It must be a cracked tooth syndrome You need a root canal filling We’ll have to do an apicectomy Sorry, we’ll have to extract the tooth Let’s explore that bone cavity Your occlusion needs adjustment You need a bite splint You’ve got “TMJ syndrome” You may need TMJ surgery
Types of Orofacial Pain Most persistent orofacial pain is odontogenic, myofascial or neuropathic in origin Myofascial: the most common non-odontogenic pain. May co-exist with, or mimic dental pain Neuropathic pain: less common, more difficult to manage. Avoid invasive procedures without clear indications! Use preemptive analgesia
Neuropathic Pain Sharp, shooting, burning, constant or intermittent Post-traumatic neuropathic pain may follow deafferentation (surgery, endodontia, trauma) Secondary hyperalgesia and allodynia may confuse diagnosis (not “atypical facial pain”) Treatment of neuropathic pain requires medications and long-term pain management
Myofascial Pain Dull, aching, deep, vary from moderate to severe Pain is often referred to other areas like the TMJ, but the pain site is not always the pain source Myofascial pain is activated by muscle overload, fatigue, trauma, cold, and emotional stress Referred pain from a TrP source can be elicited or made worse with palpation or needle insertion
Myofascial Pain Follows no dermatomal pattern. Often a history of a triggering event in the past can be identified Secondary (satellite) TrP’s commonly develop in adjacent muscles. Muscle weakness may occur Autonomic and proprioceptive concomitants often present: sweating, lacrimation, coryza, salivation; dizziness, tinnitus, imbalance Motor incoordination may occur eg masticatory muscle dysfunction in TMD
Orofacial and Head and Neck Trigger Points
X=TrP Black=primary pain Shade=secondary pain Foreman, P.A. : Chronic Orofacial Pain : A Clinical Challenge. NZ Den J. 104, No. 2: 44-48; June 2008.
Examples of TrPs
Temporalis TrPs
Medial Pterygoid TrPs
Masseter TrPs
Lateral pterygoid TrPs LifeART Medical Illustrations Royalty Free
Infraspinatus TrPs (“Arthritis”)
Gluteus Minimus TrPs (“Sciatica”)
Gluteus Medius TrPs (“Lumbago”) Supinator TrPs (“Tennis Elbow”) LifeART Medical Illustrations Royalty Free
Temporomandibular Disorders (TMD)
Temporomandibular Disorders (TMD) TMD: A group of conditions affecting the TMJ region and muscles of mastication A major cause of non-dental orofacial pain which is often diagnosed as a joint, not muscle problem Most TMDs are unrelated to occlusal dysfunction
Temporomandibular Disorders (TMD)
x x
x
TMJ or MPD?
TM joint dysfunction or referred myofascial pain?
TM Joint Dysfunction or Referred Pain From TrPs?
Medial pterygoid TrPs
Masseter TrPs LifeART Medical Illustrations
Convergence Convergence occurs throughout the body. It helps to explain referred myofascial pain Possibly explains distal acupuncture point effects. More than 70% of TrPs are located at similar locations* Convergence of afferent fibers from neck muscles (SCM, trapezius, cervical muscles) within trigeminal spinal sub-nucleus caudalis also refers pain to orofacial region Kroening and Cleson
Trapezius TrPs
Sternocleidomastoid TrPs
Trapezius TrPs
Sternocleidomastoid TrPs LifeART Medical Illustrations Royalty Free
Role of Cervical Afferents in TMD
interneurons
Temporomandibular Disorders (TMD)
x x
x
TMJ or MPD? PAINWeek 2009
Is TMD a Functional Pain Syndrome?
Functional Pain Syndromes Peripheral manifestations of altered CNS output due to increased autonomic and neuroendocrine activity Other comorbidities: –Interstitial cystitis – Irritable bladder
(HPA axis) – Chemical sensitivities – PTSD – Gulf War Syndrome – Depression – SAD
De Leeuw et al (2005) J Am Dent Assoc 136:459-468. Fricton (2004) Curr Pain Headache Rep; 8(5):355-63. Rollman et al (2000) Curr Rev Pain; 4(1):71-81. Hedenburg-Rasmussen et al (1999) Swed Dent J; 23:185-92. Korzun et al (1998) Oral Surg Oral Med Oral Path; 86:416-20. Plest et al (1996) J Rheumatology 23(11):1948-52.
Functional Pain Syndromes and TMD Many TMD patients report symptoms such as irritable bowel syndrome, migraine, premenstrual syndrome, interstitial cystitis, depression, chronic fatigue and fibromyalgia – This suggests that dysregulation of the HPA axis is likely to be an important factor in TMD Korzun et al (1998) Oral Surg Oral Med Oral Path 84: 416-420.
Role of the HPA Axis in Stress STRESS
(Fight or Flight)
HYPOTHALAMUS releases CRF PITUITARY releases ACTH
FIGHT OR FLIGHT RESPONSE
ADRENALS release cortisol and adrenaline
CHRONIC ACTIVITY CHRONIC STRESS RELATED ILLNESS
Functional Pain Syndromes and TMD Of 92 consecutive female patients seen at Univ. of Michigan Rheumatology and Chronic Fatigue Clinics:
42%: 46%: 42%: 19%:
History of TMD Hx of irritable bowel syndrome Hx of premenstrual syndrome Hx of interstitial cystitis Korzun et al 1998.
Functional Pain Syndromes and TMD Despite a history of generalized symptoms before the onset of TMD, 75% of this group had been treated exclusively for TMD Of these, 63% were prescribed bite splints –In no case was this treatment effective
“Mechanistic approaches to complex disorders are unlikely to succeed” Korzun et al 1998.
Gender and Functional Pain Syndromes  A large majority of sufferers are female Female / Male Ratio
Fibromyalgia syndrome (FMS) Chronic fatigue syndrome (CFS) Irritable bowel syndrome (IBS) Temporomandibular disorders (TMD) Seasonal affective disorder (SAD) Depression
9:1 8:1 8:1 8:1 3:1 3:1 Korzun et al 1998.
Gender and Functional Pain Syndromes Possible contributory factors
–Psychosocial stressors –Genetic factors –Environmental triggers –Reduced sensory inhibition –Endocrine factors
Myofascial Pain
What is it?
Myofascial Pain and Dysfunction: The Trigger Point Manual –Travell and Simons –Published by Williams and Watkins
Volume I : Upper Part of Body (1999 2nd ed)
Volume II : The Lower Extremities (1992)
Myofascial Pain Syndromes Myofascial Trigger Points (TrPs) –Hyperirritable spots, usually in a taut band of skeletal muscle or fascia, painful if compressed
Referred pain is common. Autonomic and/or proprioceptive signs and symptoms may occur
Peripheral and Central Pain Mechanisms are Involved Dysfunctional motor end plates (injury, repeated muscle contraction) release substances which increase local sympathetic afferent activity
Travell and Simons (1999). Williams and Wilkins. Myofascial Pain and Dysfunction:The Trigger Point Manual Vol.1 pp 62-67.
Ongoing nociceptive barrage from injury sites result in CNS wind-up and increased suffering. Central stress-related sympathetic efferents may increase or perpetuate pain by activating muscle spindles (e.g. stress can cause muscle pain) Hubbard and Berkhoff (1993). Spine 18:1803-1807
Effects of Stress (Needle EMG) 16.88
15.82
15.73
15.99
(13.38)
(14.99)
Trigger Point (18.14)
(10.07)
4.46 (3.55)
4.34 (1.99)
** M= 28.34 **SD=(20.79)
4.63 (3.65)
4.44 (2.31)
4.27 (1.95)
Non-Trigger Point --------------------------------------------Baseline Forward Rest Backward
Recovery
Counting
TASK CONDITIONS Interval
Counting (Stress)
Means (standard deviations) of mean amplitude EMG activity for TrP and non-TrP muscle across tasks.
More Examples of TrPs
Temporalis TrPs
Masseter TrPs
Medial pterygoid TrPs
Lateral pterygoid TrPs LifeART Medical Illustrations Royalty Free
Trapezius TrPs
Sternocleidomastoid TrPs
Trapezius TrPs
Sternocleidomastoid TrPs LifeART Medical Illustrations Royalty Free
Multifidi TrPs
Splenius capitis TrPs
LifeART Medical Illustrations Royalty Free
Diagnosis of Myofascial TrPs Pain (“jump sign”) seen on palpation of active TrP Key TrP: active TrP also activates satellite TrPs Satellite TrP: TrP induced by key TrP * –*deactivated by inactivation of key TrP –Latent TrP: only painful on palpation
TrP Diagnosis
Pressure Algometer
Masseter TrPs
Sternocleidomastoid TrPs
Suboccipital TrPs
Levator scapulae TrPs
Pressure Algometer “economy model�
ten cents
Persistent Orofacial Pain Management Most chronic orofacial pains are primarily myofascial or with a myofascial component Management should thus be conservative, minimally invasive, and includes adjunctive psychosocial management if needed Growing consensus that traditional treatments for TMD are unscientific and may be harmful
TMD is a chronic condition which waxes and wanes. Relief is often seen in most cases regardless of treatment – Stohler and Zarb (1999) J Orofacial Pain
Biomedical approaches alone seldom provide long-term improvement and management. Recurrences are therefore likely to occur Biopsychosocial and biomedical approaches should be used concurrently for best long term outcomes – Dworkin (1997) Oral Surg Oral Med Oral Path
Temporomandibular Disorders (TMD) Up to 90% of patients TMD improve with virtually any or no treatment. No evidence it is progressive Diagnosis and treatment varies according to beliefs of different practitioners. If good results occur, both doctor and patient will be be favorably impressed Every “clinical success” reinforces the belief that such treatment is necessary. Placebo factors are common – Greene, Academy of Orofacial Pain Meeting, 1999.
Occlusion, Splints and TMD Occlusion plays a minimal role in TMD, but it is still used to justify occlusal adjustments and intraoral appliances which can be harmful –Studies show these have little scientific validity
Positive results seen with splints are mostly due to placebo effects, remissions, natural outcomes, and clinician/patient relationships. They should be used as adjuncts, not definitive treatments Dao et al (1994) The Efficacy of Oral Splints in the Treatment of Myofascial Pain of the Jaw Muscles: A Controlled Clinical Trial. Pain 56: 85-94
The Problem with “Moras” Psychiatric conditions often not considered by dentists. “TMD” - due to obsessive oral habits. The “MORA” led to major malocclusion Mechanistic approaches to complex disorders are unlikely to succeed in such cases
Splints and TMD - Conclusions If used, splint therapy should be simple, non-harmful, and used as an adjunct to reduce oral habits and joint loading. This may relieve some symptoms, but underlying etiology must be identified, which may require a team approach Splints become ineffective if continuously worn, and can lead to dependency. They should be worn intermittently Rugh, Dolwick ADA Meeting 1994.
“Historically the field of temporomandibular disorders (TMD) has been based on testimonials, clinical opinion, and blind faith rather than on science. Reparative procedures to the joints, jaws, or occlusion are unlikely to be required for the management of chronic musculoskeletal disorders. Because of the concerns of many people regarding professional credibility and intellectual honesty, the need for scientific evidence to support the various belief systems is of paramount importance� Professor Charles McNeill, DDS Director, Center for Orofacial Pain UCSF Past President, American Academy of Orofacial Pain
McNeill con’t
“Therapeutic approaches for TMD and other orofacial pains have undergone a major evolution from our traditional mechanistic concepts to biopsychosocial concepts emphasizing multidisciplinary approaches. Advances in understanding of pain mechanisms and management of chronic pain have improved treatment outcomes. Emphasis is now on treatment and education that involves the patient in the physical and behavioral management of their own problem. Most TMD patients achieve good relief of their symptoms with noninvasive, conservative therapy� McNeill CM (1997). Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics. 83(1):51-60.
Chronic Orofacial Pain Management Communication, reassurance, education Home management program Limited use of medications Treat active myofascial trigger points Multidisciplinary pain management program Identify and manage perpetuating factors
Communication, Reassurance, Education Reduce patient anxiety through effective communication skills Many fear they have a serious, possibly life threatening disease, particularly after visiting other health professionals without success Reassurance, and education about the pain problem, is the first step towards recovery
Home Management Program The key to successful management of TMD and other orofacial pain problems Outcome studies show motivated patients who take an active part in rehabilitation make better progress. Treatment orientated, “cure” seeking patients are less likely to achieve good outcomes Foreman et al.(1994). An Evaluation of the Diagnosis, Treatment and Outcome of Patients with Chronic Orofacial Pain. New Zealand Dental Journal 90: 44.
Home Management Program Avoid chewing hard foods (no gum) Limit wide or prolonged jaw opening Avoid parafunctional habits Avoid clicking or “testing” Work position (computer) Sports, hobbies, interests (e.g. violin) Sleeping position, bed, pillow Poor sleep (sleep apnea), stimulants
Home Physical Program Moist heat applications –cold or ice packs as alternatives
Passive stretching Postural awareness Acupressure, massage
Appropriate Use of Medications Some medications may be inappropriate or ineffective, with side effects and interactions Pain medications and dosages should be time contingent not prn, and titrated Mild analgesics (OTC), low-dose tricyclics Specific meds where indicated (neuropathies) Review medications at regular intervals
Specific Procedures Vapocoolant spray and stretch* –“Spray and Stretch” (Gebauer)
Fluorimethane (withdrawn due to ozone layer effects) Ethyl chloride (care needed, excessive cooling effects) –Other Options: ice packs, cryostim probes
*Follow with warming full ROM stretches + exercises (Spray and stretch can also be used in diagnosis)
Vapocoolant Spray and Stretch (trapezius)
Trigger Point Injections
Trigger Point Injections
Physical Therapy Ultrasound Ischemic compression (acupressure) Massage therapy* Acupuncture *RCT’s evidence shows therapeutic massage is more effective than acupuncture or chiropractic treatment Symposium, American and Canadian Societies Meeting 2004
Pain Management Program Education Relaxation (PMR) Self Hypnosis Biofeedback Imagery Counseling Physical therapy –Exercise –Massage –TENS, Acup. –Ultrasound –Hydrotherapy
Persistent Myofascial Pain
If myofascial pain management is unsuccessful, undiagnosed perpetuating factors must be identified and managed
Perpetuating (Predisposing) Factors Oral parafunctional habits Psychosocial factors Systemic biologic factors or disease Genetic/skeletal/occlusal factors Postural habits Environmental factors Non-compliance
Therapeutic Massage