OROFACIAL PAIN AND TEMPOROMANDIBULAR DISORDERS
TMJ AND TMD
Does it hurt to open and close your jaw? Do you find that you have pain upon eating? TMD is a common condition associated with those symptoms.
Facial pain can be extremely debilitating and can be characterized as feeling sharp and electric to burning. Facial pain may be related to a neural condition, a TMJ related condition or even a tooth related condition.
Does your head feel like it was placed in a vice? Do you experience nausea and light sensitivity accompanied by your headache? You are not alone. Headaches are extremely common.
Sometimes a tooth may present with pain despite no evidence of infection or dental disease. Often these teeth are first treated with traditional dental procedures, but the pain still persists.
TMJ AND TMD
People often say they have TMJ when referring to jaw related pain; however, the correct term is TMD. The TMJ which is short for the temporomandibular joint is the name of the joint that connects the maxilla (upper jaw) to the mandible (lower law). Essential for chewing, speaking, eating, and drinking, the TMJ is stablized by ligaments and muscles. If the joint becomes compromised due to stress, overuse, disease or trauma, limitations in jaw function and/or pain may arise. These limitations may be extremely debilitating.
TMD Symptoms include:
pain upon opening and closing your jaw
jaw pain when eating
facial pain and tenderness
painful clicking or popping of your jaw
jaws locking closed or open
trouble biting down and putting your teeth together
headaches upon waking up
headaches in the temples
limitation in jaw range of motion
While some of the symptoms are directly related to facial muscles and/or the TMJ, othertimes, symptoms of TMJ disorder (TMD) may originate from the upper neck muscles. As an orthopedic system connected to the neck and shoulders, the TMJ may produce symptoms that radiate to the neck and shoulders, and likewise problems in the neck and shoulders may radiate to produce TMJ related symptoms.
Treatment options for TMD include:
pharmacotherapy muscular injections
oral appliance therapy
tension relieving strategies
Do you suffer from TMJ related pain?
Muscle or joint pain
Pain due to underlying medical conditions
Facial pain may stem from several causes. The first step to effectively treating your facial pain is, of course, diagnosing the origin of your pain. Causes of facial pain include:
Facial pain often arises from referred pain. Referred pain signifies that the origin of the pain differs from where the pain is felt. In other words, although you may feel pain in your face, the root of pain is from another area of your body.
Sometimes, facial pain may present as neural in nature. In other words, the nerves in the face may be altered and fire at rates that are not within the normal limits resulting in a neural pain condition. When nerves fire for a prolonged period of time, such as in a chronic pain condition, the surrounding nerves become sensitized. Nerve related pain is often described as lancinating, burning, and electric. Neuropathic or nerve related pain is not completely understood and believed to have several causes some of which are unknown (trigeminal neuralgia and glossopharyngeal neuralgia) and others related to an underlying medical condition or trauma. Chemotherapy may also induce neuropathic pain.
HOW DO I DIAGNOSE FACIAL AND NERVE PAIN?
Your visit will start with a detailed history taking during which we will discuss your pain in detail starting from when you first noticed the pain to reviewing the quality of your pain. We will also discuss your medical history and sleep hygiene. A detailed history taking is crucial for diagnosis, and thus I devote extensive time to this part of the exam. Then, I will perform a thorough evaluation that includes evaluating your cranial nerves, jaw joints, facial and neck muscles and oral cavity. During this evaluation, I am assessing not just the painful regions but also the origins of the pain as facial pain often involves referred pain.
Trigeminal neuralgia (TN), also called tic douloureux, is a nerve-related facial pain condition that affects the fifth cranial nerve. The trigeminal nerve provides the majority of sensory innervation to the face, jaw, and teeth. It is comprised of three divisions: ophthalmic maxillary, and mandibular. Often, the mandibular and maxillary divisions are commonly affected in this neural condition.
What are the symptoms of trigeminal neuralgia?
Trigeminal neuralgia is typically classified as classic trigeminal neuralgia, formerly referred to as type 1, or trigeminal neuralgia with concomitant continuous pain, previously referred to as type 2. Classic trigeminal neuralgia presents as paroxysmal in nature and is often described as lancinating and producing an electric-like sensation. Often, daily activities, such as walking or speaking, and normal stimulation, such as a gust of wind brushing against one's face may trigger an episode. The pain is brief, shock-like and may be provoked by a light touch. By contrast, trigeminal neuralgia with concomitant continuous pain presents as continuous neural pain that is moderate intensity but is accompanied by brief bursts of a burning, aching sensations. Trigeminal neuralgia may develop in areas devoid of infection or dental conditions. Thus, individuals suffering from TN may complain of pain and point to a tooth that is intact without any evidence of infection, cavity or fracture.
How do we diagnose trigeminal neuralgia?
The first step in diagnosing trigeminal neuralgia is a thorough evaluation and review of your history. Dr. Levi will review what triggers your symptoms. She will perform a comprehensive examination of your head, face, and neck, and she may order imaging to confirm a diagnosis.
How is trigeminal neuralgia treated?
Conservative therapies such as medications are usually the first line of treatment. Additionally, botox injections and nerve blocks are sometimes indicated and may be effective.
CHEMOTHERAPY-INDUCED NEUROPATHIC PAIN
Orofacial neuropathic pain is extremely common in cancer patients and may be related to head and neck radiation therapy, head and/or neck surgery, chemotherapy, a stem cell transplant, or the underlying cancer. Certain chemotherapies are associated with neuropathic pain.
What does neuropathic pain associated with chemotherapy feel like?
Similar to other neuropathic pain, chemotherapy-induced neuropathic pain may present as a toothache or throbbing jaw despite any obvious signs of a dental infection or dental disease. Often, chemotherapy-induced neuropathic pain subsides after treatment.
How is chemotherapy-related neuropathic pain treated if it does not subside after treatment?
Sometimes, though not common, chemotherapy-related neuropathy may linger and is treated similar to other neuropathic pain conditions. In other words, conservative therapies including medications or injections may be prescribed.
Uncomfortable and often debilitating, headaches can interfere with daily activities.
Extremely common, headaches affect everyone. A broad condition, headaches may present in a variety of forms, including tension-type headaches, migraines, and cluster headaches. Additionally, headaches are traditionally classified as primary or secondary headaches. Primary headaches are not associated with an underlying medical condition or disease. 90% of headaches are primary headaches, the most common of which, are tension-type headaches and migraines. Although tension-type headaches and migraines represent two different types of headaches, they often exist on a spectrum, and thus many individuals will have headaches that exhibit qualities of both tension-type and migraine headaches.
Tension-type headaches are bilateral and present with an non-pulsating band-like pain. They may be accompanied by nausea or vomiting but not both, and they may range from a moderate dull pain to aching pain. They usually last from 30 minutes to several hours. The pain associated with tension-type headaches is often across the forehead, in the temples, the back of the head and the facial muscles. Tension-type headaches are often associated with temporomandibular joint disorders (TMD). Thus, it is not uncommon for patients with TMD to present with tension-type headaches as their dominant symptom.
Migraines, by contrast, may occur on one side of the head or bilaterally (though more commonly they are unilateral) and are often described as being moderately to severely painful. They may be accompanied by an aura, vomiting and nausea and are often described as pulsating. Migraines typically last longer than tension-type headaches lasting anywhere from several hours to three days.
Cluster headaches present with severe pain unilaterally usually at the temple or by the eye. The pain duration ranges from 30 minutes to three hours and may be accompanied by a running nose or tears.
If you suffer from headaches, we can help
Headache treatments may include medication, behavioral modifications, oral appliances, botox, muscle injections, exercises, and dietary changes. Dr. Levi has extensive experience treating headaches.
Also known as atypical odontalgia, atypical facial pain, phantom tooth pain, trigeminal neuropathy or painful post-traumatic neuropathy, this condition is a pain phenomenon which presents as a persistent toothache in the absence of infection, fracture or decay. Sometimes, the pain may spread to other areas of the face or jaws.
Why is it called an atypical toothache?
It's called an atypical toothache, because it does not follow the course of a 'typical' toothache. Unlike a typical toothache which may present due to dental decay, a periodontal (gum) infection or trauma, an atypical toothache presents without these signs. Atypical odontalgia presents with persistent, throbbing or aching pain associated with a tooth, teeth, or even an extraction site that is not relieved by dental treatment.
What causes atypical odontalgia?
We don't completely understand the pain phenomenon responsible for atypical odontalgia, but we believe that it is similar to phantom limb pain. The nerves in the tooth/teeth or site of where the tooth once was (in the case of an extraction) have become sensitized and translate information to your brain which is perceived as pain. Often, these teeth are initially treated with a root canal therapy or extraction, yet the pain persists after completion of the procedure. Although we still do not completely understand what causes painful post-traumatic neuropathy, we know that it occurs more commonly in women and is more prevalent in middle-aged to older age indivdiuals.
How is atypical odontalgia diagnosed?
A thorough history, clinical examination and necessary imaging must be performed to diagnose an atypical toothache.
How is a phantom toothache treated?
The first step to treating persistent toothaches that do not respond to traditional dental treatment is accurately diagnosing this condition. After diagnosis, appropriate medications may be administered. Often, a custom made mouth guard may also be indicated. This guard helps with the delivery of the medication and differs from a night guard worn for TMJ related pain or sleep apnea.