Orofacial Pain

What Is Orofacial or Craniofacial Pain?

The specialty of Orofacial Pain Dentistry is concerned with the prevention, evaluation, diagnosis, treatment, and rehabilitation of orofacial pain disorders or  sometimes called TMD disorders. The word Craniofacial Pain has been used interchangeably with Orofacial Pain for many years. The terms orofacial and craniofacial should not confuse the patient seeking help.   

Orofacial Pain encompasses such issues that cause head and neck pain that is often non-tooth related.  It mimics TMJ problems and may also cause indirect jaw and joint dysfunction due to the pain and muscle spasm associated with it.  It involves treatment of neurovascular and tension type headaches and jaw symptoms.  It involves muscle, tendon, and ligament injuries in the face.

Orofacial pain is evolving and the scope of the field is enlarging. At the present time, orofacial pain encompasses:

• Masticatory musculoskeletal pain
• Cervical musculoskeletal pain
• Neurovascular pain
• Neuropathic pain
• Sleep disorders related to orofacial pain
• Intraoral
• Intracranial
• Extracranial
• Orofacial Dystonias 
• Headaches
• Migraines
• Facial Pain

Symptoms of Orofacial Pain

Oral facial pain includes a number of clinical problems which may include but are not limited to the following:

• Temporomandibular Disorders
• Myofascial Pain (Muscle Trigger Points)
• Muscle Spasm
• Headaches
• Migraine
• Oral Pain from teeth, gums, or bones
• Craniofacial Pain Syndromes like:
  • Temporal Tendonitis
  • Ernest Syndrome
  • Hamular Bursitis
  • Occipital Neuritis
• Arthritis (TMJ and Cervical)
• Trigeminal Neuralgia
• Cervicalgia
• Anxiety
• Depression
• Fibromyalgia
• Muscle movement Disorders (Dystonias)

Diagnosis of Orofacial Pain

Abnormal cervical relationship (Can be a clue to cervical generated pain)

A careful consideration needs to be made in the diagnosis of TMD and orofacial pain which often is time consuming. This is extremely difficult in the everyday dental office which has concerns for clean teeth, cosmetic procedures, fillings, root canals, dentures, tooth whitening, and everything else.

This is the primary reason it can be important to seek out a dentist who spends all of his or her time dealing with only TMD and orofacial pain. By taking into consideration the history and findings of the complete examination and often by using diagnostic blocks of nerves, a proper diagnosis can be made. A proper treatment plan cannot be established without a proper diagnosis, which is what almost 100% of the patients presenting to a TMJ office don’t have when they arrive.

The special needs of the pediatric and geriatric populations are considered when formulating a comprehensive treatment plan for these patients. Dr. McCarty will make a diagnosis on the basis of a detailed assessment of the character of the pain, including: duration, site, severity, character, frequency and periodicity, associated features, initiating factors and relieving factors.

We will take a medical and dental history to determine if any trauma has occurred in the facial area, perform a physical examination to examine your temporomandibular joint and look at head and neck structure. Maintaining or correcting your bite ensures optimal health and proper care, which will help reduce or eliminate orofacial pain or discomfort.

Treatment of Orofacial pain

Dr. McCarty's objective is to locate the source of the pain and alleviate it.  What is confusing about face pain is there are several sensory inputs to the trigeminal nerve system that "cross-talk" and produce similar muscle responses.  The pain may be originating from any of the trigeminal branches including any superficial or deep facial structures (teeth, gums, TMJs, bones, sinuses, skin, etc....), upper cervical areas including the C1-C3 nerves and possibly lower cervical nerves (shoulders and up), and throat. Since all 3 branches of the Trigeminal N., C1-C3, the Glossopharyngeal N., the Facial N, and the Vagus N. all contribute sensory input to the Trigeminal Nucleus, not only is there cross-talk, but also similar motor responses in the 3rd division of the Trigeminal N.  Therefore, we may see muscle tension and pain in muscles like the: masseter, temporalis, lateral pterygoid, medial pterygoid, mylohyoid, anterior digastric, tensor tympani, and tensor veli palatini.  Tension of these muscles will lead to bite changes, stuffy ears (as the tensor veli palatini and levator veli palatini are involved in ear congestion), and trigger point formation.  In my opinion many of the cases we see are from upper cervical pain and from trapezius or Sternocleidomastoid trigger points.  Many dental providers fail to find the source of the pain and treat facial pain as a bite problem.  This can lead to very expensive treatment plans.  There are different ways to alleviate pain sources which may include the following:

Treatments include:

• Appliances (Used for different reasons.)
• Physical Therapy Modalities
  • High Voltage Stimulation (Occasional use for Trigger Points or to break muscle spasm.)
  • Ultrasound (Occasional use for myositis or temporal tendonitis.)
  • Iontophoresis (Occasionally used for TMJ lateral pole inflammation.)
  • Spray & Stretch (Used to break up Trigger Points or for diagnosis.)
  • Cold Laser (Occasionally used to reduce pain and inflammation.)
  • TENS (Rarely used except for temporary pain relief.)
• Injections
  • Trigger Point Injections (Used to break up Trigger Points.)
  • Prolotherapy (Used to promote ligaments or tendon insertion repair.)
  • Steroid Injections (Used to decrease inflammation)
  • PRF (Platelet-Rich Fibrin) (Regenerative and anti-inflammatory)
  • Botox (Used to decrease uncontrolled spasm). 

• Medications (Temporarily use to reduce muscle spasm, inflammation, & decrease parafunction.)

• Surgical referral options (For arthroscopic procedures, disc plication, arthrocentesis, and occasional joint replacement.)

What about Botox?   Dr. McCarty has had Botox training but does not recommend its use except in rare circumstances.  Botox addresses the wrong end of the problem in most cases, is expensive, and it has to be repeated. I have found most individuals offering Botox as an initial treatment are not very equipped at treating orofacial pain.

 

Teeth in proper alignment (A normal bite does not equal pain free).