Facial Pain Relief in Chicago: Expertise in Trigeminal Nervous System is needed for Effective Treatment of Facial Pain, Migraine and Chronic Daily Headaches

Chronic facial pain is often seen in a very different light than other chronic pains.  For a long time Atypical Facial Pain was considered a psychiatric diagnosis   It is been reclassified and is now considered a trigeminal nerve or other cranial nerve disorder.

This type of pain is frequently associated with long term suffering and frequent misdiagnosis.  I have been treating chronic atypical facial pain for over 30 years in my Gurnee and Highland Park offices.
To learn more visit my office websites;
Highland Park:  www.ThinkBetterLife.com
Gurnee:   www.DelanyDentalCare.com

The ICD 10 coding for atypical facial pain or persistent idiopathic facial pain is as follows.

13.18.4	Persistent idiopathic facial pain [G50.1]	G44.847
Previously used terms	Atypical facial pain

THE DESCRIPTION OF THIS PAIN IS VERY SIMPLE AND COULD EASILY BE A MYOFASCIAL OR TMD CONDITION.  IT IS CONSIDERED DIFFERENT THAN HEADACHES OR MIGRAINES

Description:

Persistent facial pain that does not have the characteristics of the cranial neuralgias described above and is not attributed to another disorder.

Diagnostic criteria:

1. Pain in the face, present daily and persisting for all or most of the day, fulfilling criteria B and C
2. Pain is confined at onset to a limited area on one side of the face¹, and is deep and poorly localised
3. Pain is not associated with sensory loss or other physical signs
4. Investigations including x-ray of face and jaws do not demonstrate any relevant abnormalit

POSSIBLY THE BEST METHOD OF CLASSIFYING THESE PAINS MAY NOT BE THE DESCRIPTION OF THE PAIN BUT RATHER WHAT THE PAIN RESPONDS TO.

SPB Blocks have been used for years to treat headaches, migraines and other pain disorders.  Sluders neuralgia was origiinally described in 1908 but is sometimes considered the original TMJ diagnos prior to the diagnosis of Costen's syndrome.  

The diagnosis of contact point headaches also known as Anterior Ethmoid neuralgia, pterygopalatine ganglion neuralgia, Sluder's Neuralgia and sphenopalatine Ganglion neuralgia often presents as pain of unknown orgin .  It can respond to SPG Blocks but in general is very resistant to diagnosis.

This condition may be a nerve compression syndrome but it can spread pain anywhere in the opthalmic or maxillary divisions or the Trigeminal Nerve.

The pain follows a similar pattern as trigger points in pterygoid, masseter and temporalis muscles.  It can sometimes be relieved by decongestants such as Afrin that shrink the nasal tissues.

Neuromuscular Dentistry in conjunction with SPG Blocks, Trigger Point injections, Spray and Stretch, prolotherapy is still the most effective approach to chronic facial pain.

All work should begin with reversible therapy and permanent changes should only be done after extended relief of pain.

#ChicagoMigraines, #ChicagoContactHeadache, #ChicagoSPGBlock, #ChgicagoImprovingQualityof Life, #IllinoisFacialPain

New Article ties Joint hypermobility syndrome to migraines. This has long been known to be a factor in TMJ disorders and associated headaches.

Studies have shown that hypermobility syndrome is associated with chronic headache disorders. This new study shows that 75% of study group with the syndrome had migraines compared to only 43% of controls.

Patients with Chronic Daily Headaches, Migraines, Tension-type headaches, myofascial pain and associated headaches, atypical migaine, classic migraine almost always are headaches related to the masticatory system, the trigeminal nerve and TMJ disorders(TMD). These problems are often best addressed by the use of a diagnostic neuromuscular orthotic that has been shown in various studies to give some improvement in close to 100% of patients. Almost all studies of orthotics (of all types) show better then 50 % of patients experiencing considrable improvement and in my experience neuromuscular orthotics are far superior to the typical orthotic. Patients with migraines and/or muscular headaches would be well advised to consider temporomandibular disorders as part of a differential diagnosis.

Unfortunately for most patients with migraines neurologists will usually begin with drug trials in spite of side effects and statistically lower response rates. Patients usually turn to neuromuscular dentistry after years of suffering. often the suffering was needless. Most physicians are not well informed about the field of neuromuscular dentistry.

Recent articles from the International Acadery of Dental Research have done an enormous disservice to patients by promoting the psychological and biosocial aspects of chronic pain strongly supporting the notion that drug therapy should precede occlusal therapy. This is a biased view that is particularly destructive to patients labeling their pain as a psychosocial disorder to be treated by drugs ignoring the underlying neuromuscular systems and trigemino-vascular connections that are best treated by neuromuscular orthotics.

I have listed a few of the 211 PubMed.gov abstracts below that are revealed by searching PubMed with these search terms; joint hypermobility , tmj

The study showed that "The adjusted odds ratio for the prevalence of migraine was 3.19 in JHS patients" and that " The rate ratios for migraine frequency and headache-related disability were 1.67 for JHS patients"

The authors stated "Our study suggests that JHS is a clinical disorder strongly associated with an increased prevalence, frequency, and disability of migraine in females."

Hypermobility symptom is a major risk factor for TMJ (TMD) disorders


Cephalalgia. 2011 Feb 2. [Epub ahead of print]
Joint hypermobility syndrome: A common clinical disorder associated with migraine in women.
Bendik EM, Tinkle BT, Al-Shuik E, Levin L, Martin A, Thaler R, Atzinger CL, Rueger J, Martin VT.

University of Cincinnati College of Medicine, USA.
Abstract
Preliminary studies suggested that headache disorders are more common in patients with joint hypermobility syndrome (JHS). The objectives of this study were to determine if the prevalence, frequency, and disability of migraine differ between female patients with JHS and a control population. Twenty-eight patients with JHS and 232 controls participated in the case-cohort study. Participants underwent a structured verbal interview and were assigned a diagnosis of migraine based on criteria of the International Classification of Headache Disorders, 2nd Edition. The primary outcome measures were the prevalence, frequency, and headache-related disability of migraine. Logistic regression was used for the prevalence analysis and Poisson regression for the frequency and disability analyses. Results indicated that the prevalence of migraine was 75% in JHS patients and 43% in controls. The adjusted odds ratio for the prevalence of migraine was 3.19 (95% CI 1.24, 8.21] in JHS patients. The rate ratios for migraine frequency and headache-related disability were 1.67 (95% CI 1.01, 2.76) and 2.99 (95% CI 1.66, 5.38), respectively, for JHS patients. Our study suggests that JHS is a clinical disorder strongly associated with an increased prevalence, frequency, and disability of migraine in females.

PMID: 21278238 [PubMed - as supplied by publisher]

Acta Odontol Scand. 2010 Sep;68(5):289-99.
Risk factors associated with incidence and persistence of signs and symptoms of temporomandibular disorders.
Marklund S, Wänman A.

Department of Odontology, Umeå University, Sweden. susanna.marklund@odont.umu.se
Abstract
OBJECTIVE: To analyze whether gender, self-reported bruxism, and variations in dental occlusion predicted incidence and persistence of temporomandibular disorder (TMD) during a 2-year period.

MATERIAL AND METHODS: The study population comprised 280 dental students at Umeå University in Sweden. The study design was that of a case-control study within a 2-year prospective cohort. The investigation comprised a questionnaire and a clinical examination at enrolment and at 12 and 24 months. Cases (incidence) and controls (no incidence) were identified among those without signs and symptoms of TMD at the start of the study. Cases with 2-year persistence of signs and symptoms of TMD were those with such signs and symptoms at all three examinations. Clinical registrations of baseline variables were used as independent variables. Odds ratio estimates and 95% confidence intervals of the relative risks of being a case or control in relation to baseline registrations were calculated using logistic regression analyses.

RESULTS: The analyses revealed that self-reported bruxism and crossbite, respectively increased the risk of the 2-year cumulative incidence and duration of temporomandibular joint (TMJ) signs or symptoms. Female gender was related to an increased risk of developing and maintaining myofascial pain. Signs of mandibular instability increased the risk of maintained TMD signs and symptoms during the observation period.

CONCLUSION: This 2-year prospective observational study indicated that self-reported bruxism and variations in dental occlusion were linked to the incidence and persistence of TMJ signs and symptoms to a higher extent than to myofascial pain.

PMID: 20528485 [PubMed - indexed for MEDLINE]

J Orofac Pain. 2009 Fall;23(4):303-11.
Evaluation of the Research Diagnostic Criteria for Temporomandibular Disorders for the recognition of an anterior disc displacement with reduction.
Naeije M, Kalaykova S, Visscher CM, Lobbezoo F.

Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), Research Institute MOVE, University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands. m.naeije@acta.nl
Comment in:

J Orofac Pain. 2009 Fall;23(4):312-5; author reply 323-4.
J Orofac Pain. 2009 Fall;23(4):320-2; author reply 323-4.
J Orofac Pain. 2009 Fall;23(4):316-9; author reply 323-4.
Abstract
The aim of this Focus Article is to review critically the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) for the recognition of an anterior disc displacement with reduction (ADDR) in the temporomandibular joint (TMJ). This evaluation is based upon the experience gained through the careful analysis of mandibular movement recordings of hundreds of patients and controls with or without an ADDR. Clinically, it is a challenge to discriminate between the two most prevalent internal derangements of the TMJ: ADDR and symptomatic hypermobility. It is due to the very nature of these derangements that they both show clicking on opening and closing (reciprocal clicking), making reciprocal clicking not a distinguishing feature between these disorders. However, there is a difference in timing of their opening and closing clicks. Unfortunately, it is not feasible to use this difference in timing clinically to distinguish between the two internal derangements, because it is the amount of mouth opening at the time of the clicking which is clinically noted, not the condylar translation. Two other criteria proposed by the RDC/TMD for the recognition of an ADDR are the 5-mm difference in mouth opening at the time of the opening and closing clicks, and the detection of joint sounds on protrusion or laterotrusion in case of non?reciprocal clicking. These, however, run the risk of false-positive or negative results and therefore have no great diagnostic value. Instead, it is recommended that the elimination of clicking on protrusive opening and closing be examined in order to distinguish ADDRs from symptomatic hypermobility.

PMID: 19888478 [PubMed - indexed for MEDLINE]

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Jun;107(6):e54-7.
Joint hypermobility and disk displacement confirmed by magnetic resonance imaging: a study of women with temporomandibular disorders.
Sáez-Yuguero Mdel R, Linares-Tovar E, Calvo-Guirado JL, Bermejo-Fenoll A, Rodríguez-Lozano FJ.

Faculty of Medicine, University of Murcia, Murcia, Spain. mrosario@um.es
Abstract
OBJECTIVE: The objective of this study was to test whether or not there is an association between generalized joint hypermobility (measured using the Beighton score) and temporomandibular joint disk displacement in women who had sought medical attention for temporomandibular disorders (TMD).

STUDY DESIGN: We studied 66 women who were attending the clinic for TMD. The patients were examined for joint hypermobility, and Beighton scores were calculated. When it was suspected that a patient suffered arthropathic complaints, magnetic resonance imaging of both temporomandibular joints was performed with the mouth closed and at maximal opening. The Pearson chi-squared test was used to test for an association between generalized joint hypermobility and disk displacement.

RESULTS: We were unable to confirm the existence of an association between generalized joint hypermobility and temporomandibular joint disk displacement in women (chi(2) = 1.523; P = .02).

CONCLUSION: Generalized joint hypermobility may be a factor related to TMD, but we did not find an association between generalized joint hypermobility and anterior disk displacement in women.

PMID: 19464645 [PubMed - indexed for MEDLINE]

Eur J Oral Sci. 2008 Dec;116(6):525-30.
Association between generalized joint hypermobility and signs and diagnoses of temporomandibular disorders.
Hirsch C, John MT, Stang A.

Department of Pediatric Dentistry, School of Dentistry, University of Leipzig, Leipzig, Germany. christian.hirsch@medizin.uni-leipzig.de
Comment in:

J Evid Based Dent Pract. 2010 Jun;10(2):91-2.
Abstract
The aim of this study was to analyze whether generalized joint hypermobility (GJH) is a risk factor for temporomandibular disorders (TMD). We examined 895 subjects (20-60 yr of age) in a population-based cross-sectional sample in Germany for GJH according to the Beighton classification and for TMD according to the Research Diagnostic Criteria for TMD (RDC/TMD). After controlling for the effects of age, gender, and general joint diseases using multiple logistic regression analyses, hypermobile subjects (with four or more hypermobile joints on the 0-9 scale) had a higher risk for reproducible reciprocal clicking as an indicator for disk displacement with reduction (Odds Ratio (OR) = 1.68) compared with those subjects without hypermobile joints. Concurrently, subjects with four or more hypermobile joints had a lower risk for limited mouth opening (< 35 mm; OR = 0.26). The associations between GJH and reproducible reciprocal clicking or limited mouth opening were statistically significant in a trend test. No association was observed between hypermobility and myalgia/arthralgia (RDC/TMD Group I/IIIa). In conclusion, GJH was found to be associated with non-painful subtypes of TMD.

PMID: 19049522 [PubMed - indexed for MEDLINE]

Publication Types, MeSH Terms



Dentomaxillofac Radiol. 2010 Dec;39(8):494-500.
Evaluation of the lateral pterygoid muscle using magnetic resonance imaging.
D'Ippolito SM, Borri Wolosker AM, D'Ippolito G, Herbert de Souza B, Fenyo-Pereira M.

Rua Prof Filadelfo Azevedo, 617, apt. 61, 04508-011, São Paulo, SP, Brazil. silvia.dippolito@uol.com.br
Abstract
OBJECTIVES: The aims of this study were to evaluate the visibility of the lateral pterygoid muscle (LPM) in temporomandibular joint (TMJ) images obtained by MRI, using different projections and to compare image findings with clinical symptoms of patients with and without temporomandibular disorders (TMD).

METHODS: In this study, LPM images of 50 participants with and without TMDs were investigated by MRI. The images of the LPM in different projections of 100 TMJs from 35 participants (70 TMJs) with and 15 participants (30 TMJs) without clinical signs and symptoms of TMD were visible and analysed.

RESULTS: The oblique sagittal and axial images of the TMJ clearly showed the LPM. Hypertrophy (1.45%), atrophy (2.85%) and contracture (2.85%) were the abnormalities found in the LPM. TMD signs, such as hypermobility (11.4%), hypomobility (12.9%) and disc displacement (20.0%), could be seen in TMJ images. Related clinical symptoms, such as pain (71.4%), articular sounds (30.4%), bruxism (25.7%) and headache (22.9%), were observed.

CONCLUSIONS: Patients with TMD can present with alterations in the LPM thickness. Patients without TMD also showed alterations, such as atrophy and contracture, in TMJ images. Recognition of alterations in the LPM will improve our understanding of clinical symptoms and pathophysiology of TMD, and may lead to a more specific diagnosis of these disorders.

PMID: 21062943 [PubMed - indexed for MEDLINE

Sleep and TMJ Disorders

Patients with TMJ disorders should be evaluated for sleep disorders according to a new article in Sleep. Primary Insomnia was associated with hyperalgesia or an increased pain response. It may also be associated with central senssitazation that is found in migraines, fibromyalgia and TMD and may be a causitive factor in idiopathic pain (pain of unknown orgins)

The NHLBI (National Heart Lung and Blood Institute considers Sleep Apnea to be a TMJ disorder. The paper "Cardiovascular and Sleep Related consequences of TMJ Disorders can be found at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf

PATIENTS WITH TMJ DISORDERS AND SLEEP PROBLEMS SHOULD BE EVALUATED BY A SLEEP PHYSICIAN! FOR MORE INFORMATION ON SLEEP APNEA, DANGERS AND TREATMENT SEE http://www.ihatecpap.com

MORNING HEADACHES ARE USUALLY THE RESULT OF TMD OR SLEEP APNEA
BRUXISM IS OFTEN A SECONDARY RESULT OF SLEEP APNEA


PubMed abstract is supplied for your convenience.
Sleep. 2009 Jun 1;32(6):779-90.
Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder.

Smith MT, Wickwire EM, Grace EG, Edwards RR, Buenaver LF, Peterson S, Klick B, Haythornthwaite JA.
Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD, USA. msmith62@jhmi.edu
STUDY OBJECTIVES: We characterized sleep disorder rates in temporomandibular joint disorder (TMD) and evaluated possible associations between sleep disorders and laboratory measures of pain sensitivity. DESIGN: Research diagnostic examinations were conducted, followed by two consecutive overnight polysomnographic studies with morning and evening assessments of pain threshold. SETTING: Orofacial pain clinic and inpatient sleep research facility. PARTICIPANTS: Fifty-three patients meeting research diagnostic criteria for myofascial TMD. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: We determined sleep disorder diagnostic rates and conducted algometric measures of pressure pain threshold on the masseter and forearm. Heat pain threshold was measured on the forearm; 75% met self-report criteria for sleep bruxism, but only 17% met PSG criteria for active sleep bruxism. Two or more sleep disorders were diagnosed in 43% of patients. Insomnia disorder (36%) and sleep apnea (28.4%) demonstrated the highest frequencies. Primary insomnia (PI) (26%) comprised the largest subcategory of insomnia. Even after controlling for multiple potential confounds, PI was associated with reduced mechanical and thermal pain thresholds at all sites (P < 0.05). Conversely, the respiratory disturbance index was associated with increased mechanical pain thresholds on the forearm (P < 0.05). CONCLUSIONS: High rates of PI and sleep apnea highlight the need to refer TMD patients complaining of sleep disturbance for polysomnographic evaluation. The association of PI and hyperalgesia at a nonorofacial site suggests that PI may be linked with central sensitivity and could play an etiologic role in idiopathic pain disorders. The association between sleep disordered breathing and hypoalgesia requires further study and may provide novel insight into the complex interactions between sleep and pain-regulatory processes.