OROFACIAL PAIN AND TEMPOROMANDIBULAR DISORDERS
TMJ AND TMD
TMD is a general term to describe pain that can arise from the jaw joint and its related structures. It can be associated with limited mouth opening, pain with chewing and eating and headaches.
FACIAL PAIN
Facial pain can be extremely debilitating and may range in quality from sharp and electric to burning to pressure. Facial pain may be related to a neural condition, a TMJ related disorder, a headache disorder or even a tooth related condition.
HEADACHES
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.
TOOTH PAIN
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
TMJ is often the term used to describe jaw pain; however, this is a colloquial misnomer. The TMJ which stands for the temporomandibular joint is the name of the joint that connects the mandible (lower jaw) to the skull. Essential for chewing, speaking, eating, and drinking, the TMJ is stabilized by tendons, 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.
What are the symptoms of TMJD also known as TMD?
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pain upon opening and closing your jaw
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jaw pain when eating
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ear pain
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clogged ears or sensation of ear fullness
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ringing in the ears (tinnitus)
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dizziness
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facial or sinus pressure
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toothaches
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facial pain and tenderness
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painful clicking or popping of your jaw
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sound of jaw crunching
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jaws locking closed or open
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trouble biting down and putting your teeth together
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tension-type headaches
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migraine
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neck soreness or tension
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shoulder pain or tension
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limitation in jaw range of motion
What causes TMD?
TMD encompasses painful conditions that can arise from trauma or disease to the temporomandibular joint as well as the muscles and ligaments that support it. While some of the symptoms are directly related to facial muscles and/or the TMJ, other times, 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.
Some causes include:
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teeth grinding (bruxism)
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teeth clenching
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parafunctional habits (biting nails, cuticles)
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holding tension in your face
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neck and shoulder muscle pain (myofascial pain)
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arthritis
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auto-immune conditions
How is TMD treated?
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pharmacotherapy and medications
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therapeutic injections
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trigger point injections
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botox injections
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joint injections
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behavioral modifications and tension relieving strategies
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sleep hygiene
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oral appliance therapy
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dietary modifications
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physical therapy modalities
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ultrasound
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photobiomodulation
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Do you suffer from TMJ-related pain?
Dr. Lauren Levi can help.
FACIAL PAIN
Facial pain may stem from several causes. The first step in effectively treating facial pain is diagnosing the origin of the 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 the pain is from another area of your body.
NERVE PAIN
Sometimes, facial pain may present as neurogenic or neuropathic 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 neuropathic 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. Nerve pain may be paroxysmal in nature or constant with varying degrees of intensity. Cranial neuralgias often present as paroxysmal. Neuropathic or nerve-related pain is not completely understood and is believed to have several causes some of which are unknown (such as cranial neuralgias including 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 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 neck, 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
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 eating 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.
Besides trigeminal neuralgia what are some other neuralgias that Dr. Levi treats?
Dr. Levi treats other neuralgias including post-herpetic neuralgia, occipital neuralgia, glossopharyngeal neuralgia, nervus intermedius neuralgia and superior laryngeal neuralgia.
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.
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Muscle, tendon, or joint pain
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Nerve Pain
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Pain due to underlying medical conditions
Persistent Toothache
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 individuals.
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 medication stent may also be indicated. This stent helps with the delivery of the medication. Other treatment options include nerve blocks.