Headaches, Ear Pain, Mouth, Jaw and Tooth Pain related to TMJ, Whiplash and Unstable Atlas

Frank: What are the costs of treatment and is it covered by insurance? I have severely ground teeth. I clench a lot but mostly during day. 61 yrs old I do TMJ massage and that slightly helps. The headaches occur 4-10 times month. Headaches are inside my ears, above ears, in mouth and jaw and seem to sometimes be in the teeth and roof of mouth. I had whiplash injury. When I have atlas aligned it helps but does not stay in alignment.

Dr Shapira response: Insurance sometimes covers part of the cost but most insurance companies are worried primarily about shareholders and profits. Several years ago Chicago HMO agreed to pay 100% of the costs even though it was specifically excluded by their policy. Dr Mitchell Trubitt was the medical director after I showed him (trial of 6 patients) that covering TMJ disorders and neuromuscular dentistry saved them money. For many years I saw 15-25 new Chicago HMO patients patients a month and sometimes more. Success was incredible when cost was not an issue. Unfortunately United Health Care bought out Chicago HMO and they did not continue coverage. An article in Crano showed a 300% increase in medical costs in every field of medicine (except obstetrics) in patients with TMJ disorders.

As to your symptoms and treatment, I would suggest you have and examination and a diagnostic neuromuscular orthotic. It will protect your teeth from damage and address the myofascial pain it sounds like you are having.

Are you complete free of pain on your non-headache days or is the pain at more tolerable levels. Many patients "live" on drugs like ibuprofen and count headache days only when it doesn't work. The cost of living in pain is far greater than the cost of treatment. Chronic pain can suck the life out of you and the joy out of life.

The whiplash and Atlas are directly related to the jaw muscles and jaw joint and it is almost impossible to have a stable atlas / axis / craio articulation without correcting jaw position. The mandible acts like a counterbalance to the head and should be considered "the last vertebrae" which must be stabilized in a healthy position.

A diagnostic neuromuscular orthotic is the best way to determine if treatment will be effective. The orthotic is a reversible treatment that can be a life changer.

Frank: I'm in California? Is that a problem?

My headaches (or severe muscle pain in head neck teeth ears etc.) somedays is completely gone. But if I touch certain muscles they always feel like spasms and are very painful. Even 2 muscles on the side of my neck. Will it help to have all teeth capped to get them back to proper height? Will the cartilage that's wornoff ever grow back? Massage helps some I think? Cold laser helps quite a bit but I will have to do it forever. I no longer grind teeth,I just clench my jaw during the day even though my teeth aren't touching. I probably use 6-10 advil a month. But I use certain homeopathics and ice-cold therapy which are intermittent. ??????????????? I dream of a headache free pain free life.... Sometimes my headache so to speak is in my throat and in the teeth themselves and center of the ears. TKU Frank

Dr Shapira response: Frank, I don't think your pain is ever gone if the muscles are still painful to touch. It just means your pain level is below threshold but it takes a lot of energy to control pain and keep it below threshold. I term that energy "vital energy" it is the energy that makes you happy and lets you enjoy life rather than merely tolerate living. Do not start with having your teeth capped. What if it makes the pain worse. Start with a removable diagnostic neuromuscular orthotic that will let you treat the problem and evaluate success before making irreversible changes. Proceed with caps or other permanent correction only after controllling or eliminating pain to where you have a good quality of life. It is unlikely that cartilage that is totally gone will grow back but damaged cartilage can heal if it is given an ideal situation for healing.

Cold laser is safe but usually not long lasting. Trigger point injections tend to give more lasting results with hot trigger points in muscles. Spray and stretch can give amazing results. The pain patterns you describe are myofascial pain but that is just a guess without an exam.

California, is that a problem? I see long distance patients but to be successful I need several days intensive treatment to try to reach a relative homeostasis. My office can accomadate you but the first series of visits would be Monday thru Wednesday or Thursday and would require you arriving Sunday. Your original question about costs and insurance comes into play because the diagnostic stage of treatment including diagnostic orthotic, trigger points, etc may be an out of pocket expense. I would probably want to have my A/O chiropracter evaluate your Atlas after delivery of an appliance Monday afternoon.

Treatment is all about quality of life and relief of pain. There are no guarantees but my goal is to relieve as much pain as possible. I recently treated a woman who spent 50 years with a continuous headache and received total relief. I did do a reconstruction on that patient (wife of a physician) but only AFTER the pain was relieved.

TMJ disorders, headaches and facial pain frequently involve cervical musculature. Acute pain relief is accomplished with cervical muscle injection

An article (pubmed abstract below) in the Journal of Orofacial Pain. "Treatment of acute orofacial pain with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 114 patients." dicusses the use of cevical intramuscular injections to turn off acute pain in the ER. The study showed that 94% of patients had complete of partial relief with injection of a long acting anaesthetic.

There is a connection between the jaw and the neck that is incredibly important in the treatment of muscular headaches, facial pain, migraines, chronic daily headaches and TMJ disorders (TMD). The jaw acts as a counter-balance to the head and allows maintenance of head posture minimal excessive muscle adaptation. This is well described mathematically in engineering terms in the "Quadrant Theorem of Guzay". The jaw position is vital to body posture and abberations in jaw position can act as a descending disorder that can effect the entire body.

Forward head posture is frequently seen in TMJ and Headache patients. This forward posture cause exponential increases in muscle work just to maintain head posture.

Rcobado estimated that it takes double the muscle work from cervical muscles to low back for every centimeter of forward head posture, Three centimeters forward head posture would increase chronic muscle adaptation 8 fold (2X2X2=8) while a 5 centimeter forward head posture would increase it 32 times (2X2X2X2X2=32). The reason muscular injections work so well in relieving acute and chronic headaches and facial pain is that these muscles are grossly overworked in TMD patients.

Treating the muscles can give relief of acute pain but returning the system to a more normal physiologic state can give long term relief to patients.

A diagnostic neuromuscular orthotic allows the jaw to function in an ideal physiologic position. This allows gradual restoration of normal head posture and a return to normal physiologic function of the neck. I work closely with Atlas Orthogonal and/or NUCCA Chiropracters to correct the first two vertebrae early in treatment. These areas are especially prone to problems in TMD patients. As the foward head posture occurs the patient must rotate their head on the Atlas and Axis (first to vertebrae) to maintain sight lines. This is well explained by the Quadrant Theorem of Guzay which shows that the actual center of rotation for the jaw when both rotation and traslation movements are calculated is on the odontoid process of the Axis (2nd vertebrae)

Patients with TMD who are in car accidents never recover fully if their jaw issues are not addressed.

Posturology is the study of whole body posture. Posturology recognizes the importance of the jaw position. The normal swallow is a neuromuscular resetting procedure but most TMD patients have deviant or reversed swallows and are not even aware they swallow wrong. This can lead to GI problems but is primarily a structural problems that makes long term successful treatment of pain impossible without correction of neuromuscular jaw issues. A diagnostic orthotic allows patients to experience relief of head and neck pain prior to and permenant occlusal alterations.


J Orofac Pain. 2008 Winter;22(1):57-64.
Treatment of acute orofacial pain with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 114 patients.
Mellick LB, Mellick GA.
Source
Department of Emergency Medicine, Medical College of Georgia, Augusta, Georgia, USA. lmellick@mcg.edu
Abstract
AIMS:
To describe 1 year's experience in treating orofacial pain with intramuscular injections of 0.5% bupivacaine bilateral to the spinous processes of the lower cervical vertebrae.

METHODS:
A retrospective review of 2,517 emergency department patients with discharge diagnoses of a variety of orofacial pain conditions and 771 patients who were coded as having had an anesthetic injection between June 30, 2003 and July 1, 2004 was performed. The records of all adult patients who had undergone paraspinous intramuscular injection with bupivacaine for the treatment of an orofacial pain condition were extracted from these 2 databases and included in this retrospective review. Pain relief was reported in 2 different ways: (1) patients (n = 114) were placed in 1 of 4 orofacial pain relief categories based on common clinical experience and face validity and (2) pain relief was calculated based on patients' (n = 71) ratings of their pain on a numerical descriptor scale before and after treatment.

RESULTS:
Lower cervical paraspinous intramuscular injections with bupivacaine were performed in 118 adult patients. Four charts were excluded from review because of missing or inadequate documentation. Pain relief (complete or clinical) occurred in 75 patients (66%), and partial orofacial pain relief in 32 patients (28%). No significant relief was reported in 7 patients (6%). Overall, some therapeutic response was reported in 107 of 114 patients (94%). Orofacial pain relief was rapid, with many patients reporting complete relief within 5 to 15 minutes.

CONCLUSION:
This is the first report of a large case series of emergency department patients whose orofacial pain conditions were treated with intramuscular injections of bupivacaine in the paraspinous muscles of the lower neck. The findings suggest that lower cervical paraspinous intramuscular injections with bupivacaine may prove to be a new therapeutic option for acute orofacial pain in the emergency department setting.