Trigeminal Nerve Pain or TMJ? Neuromuscular Dentistry or SPG Blocks may help solve problems.

Question: My dentist diagonesed that I might have a TMJ problem, previously had MRI scan for trigeminal nerve pain but came negative, what could the problem be?

Dr Shapira Response: The trigeminal nerve supplies approximately 50% of all input to the brain. Because the MRI scan was normal does not mean the pain is not from or mediated by the trigeminal nerve. This can include TM Joint problems, TMD, Myofascial Pain, otalgia (trigeminal). All of these problems are mediated by the trigeminal nerve which is why neuromuscular dentistry is such an effective approach to chronic pain of the head and neck.

Sphenopalatine Ganglion Blocks can address the autonomic connections of the trimeninal nerve. It is usually a simplification to just call something a "TMJ" problem because there are usually multiple concerns based on symptomatology.

I normally spend an hour or more reviewing the history of patients with pain. The patient gave me no information about the SYMPTOMS that caused her to seek treatment. An accurate chronological history is an essential element in understanding how to approach a problem to bring relief. An MRI will show organic problems but are rarely the diagnostic approach to chronic pain. It is helpful in that it rules out tumors, growths, etc.

An examination of the craniomandibular and cervical musculature is incredibly important in anyone with headaches, facial pain, migraines, trgeminal pain, ear or jaw pain. Evaluation of the TM Joints and jaw motion is also very important.

The Neuromuscular Diagnostic work-up includes EMG evaluation of the jaw and/or neck muscles, Computerized scans of jaw movement and function, Sonography is sometimes used as well.

Intense Migraines: Trigeminal Neuralgia, Trigeminal Neuropathy or a simple problem best addressed through Neuromuscular Dentistry and an orthotic.

Carolyn: Intense migrane headaches with jaw, neck, shoulder, face, sinues,eye and ear pain, also numb feeling on face. I had MRI's done of my head and neck and was diagnosed with Trigeminal Neuralgia, seeked Gamma Knife, was told I wasn't a canidate and to have an MRI of my neck, had that done, nothing showed up, then was told I had Trigeminal Neuropothy. I was diagnosed with TMJ a long time ago and had a mouth piece...it didn't do much and as time went on things got worse. I am convienced that my problem is with the Tri nerves and TMJ...no doctor has caught on. I am at my wits end and need to find out what is wrong with my neck and face. Please help me in finding a doctor who could figure out my problem. Thank you!!

Dr Shapira response: Carolyn, I am sorry your life is being destroyed by what sounds like horrible pain. I would strongly suggest avoiding Gamma Knife surgery as a first line treatment.

You did not mention trying non-invasive or minimally invasive treatment such as massage therapy, chiropractic adjustment or Ice Down Therapy which can be helpful. The beauty of Neuromuscular Dentistry is that results can be rapid, amazing and life changing in just a few visits. I would suggest starting with very simple diagnostic evaluation such as spray and stretch with vapo-coolant for myofascial pain, trigger point injections SPG blocks and most importantly a diagnostic neuromuscular orthotic.

I frequently see long distance patients and we can sometimes produce amazing results in just wo to three days of intensive therapy. We do our consultation , work-up and exam the morning of the first day and deliver an orthotic that afternoon. We deactivate trigger point injections with spray and stretch techniques as described by Dr Janet Travell. The second morning we adjust the appliance and do diagnostic/treatment trigger points and blocks and adjust again that afternoon. I work closely with an Atlas orthoganol DC who can address the cervical vertebrae during your stay.

There is no "CURE" for these problems but rapid relief is possible and the orthotic lets you maintain comfort. A real "CURE" would mean you could get back the years you lost to pain, reverse the effects on your life, your relationships and your family. The best we can do is give you a brighter future.

All of the symptoms you descibed are why TMJ disorders are called "The Great Imposter"

Read "Suffer No More: Dealing With The Great Imposter" in Sleep and Health Journal http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor

Contact my office if you would like to schedule a 3 day series of appointments for rapid evaluation and treatment or I will try to find you a knowledgable doctor in your area.

intense jaw pain on left side, swollen jaw and cheek, no dental issues per dentist and endodontist...tmj or trigeminal neuralgia?

I recently received a e-mail from a patient with the following complaint:

intense jaw pain on left side, swollen jaw and cheek, no dental issues per dentist and endodontist...tmj or trigeminal neuralgia?

The question TMJ or Trigeminal Neuralgia is very limited. 95% of all pain that patients experience is muscle pain. Many patients have severe or even excruciating pain but their TM Joints are normal. These are neuromuscular problems and may have many contributing factors. Trigeminal Neuralgia is rarely the cause of pain and when it is there is usually very specific triggers. The pain usually comes and goes going from normal to intense pain after stimulating trigger.

KI have seen patients with similar symptoms that are later tracked back to cracked toooth syndrome that was not evident early on. Vacumn sinusits can also give similar symptoms.

That said, the most common cause of pain is myofascial pain acute muscle spasm, myositis or other pain of muscular orgin.

A simple test that all general dentists and/or endodontists should know is how to do trigger point deactivation with a vapocoolant and stretch that can often give instanyt pain relief. Use of a diagnostic block to the muscle can also correct these problems when used to make a differential diagnosis.

The patient did not describe whether the pain was affected by jaw movement, if there was limited opening, or many other vital facts to know if there was joint involvement.

The correct approach is to make an accurate diagnosis. This involves a thorough evaluation of the jaw musclesand (TMJ) joints but also the head and neck musculature.

The best route is to seek out a neuromuscular dentist who is trained to evaluate and correct these problems.

I frequently see patients in Chicago who have not found help locally.

Diagnosis is the key to successful treatment. Treatment should be reversible until significant pain relief is accomplished and both the patient and the doctor are comfortable with primary and secondary diagnosis.

Neuromuscular Dentistry, Central Sensitization and Trigeminal Neuralgia: Is Neuromuscular Dentistry an ideal method to prevent central sensitization?

A new article in Medical Hypothesis (see Pub Med abstract below) on Atypical Trigeminal Neuralgia discusses the pathogenisis of Central Sensitization in patients with Trigeminal Neuralgia. A percentage of patients with Trigeminal Neuralgia will have pressure on the trigeminal nerve either from blood vessels or tumors usually in the area of the foramen ovale.

Many patients who have trigeminal neuralgia have no overt cause for the disorder. When there is a tumor or blood vessel creating undue pressure on the nerve a surgiclal approach is usually corrective but the central sensitization may remain. This article postulates that time is of the essence and the longer the pain persists the more likely that brain plasticity will lead to long term central sensitization. Decompression should be done ASAP according to that line of thought.

The majority of patients diagnosed with trigeminal neuralgia do not have tumor or blood vessels encroaching on the trigeminal nerve. It is well known that treatment of TMJ disorders is highly effective in reducing pain and that Neuromuscular Dentistry has been shown to be "overwhelmingly successful" according to Dr Barry Cooper and published in Cranio Journal.

The same rationale that says the key to preventing central sensitiztion is to address the problem as soon as possible also holds true with neuromuscular problems affecting the jaws, bite, jaw muscles and TMJ (TM Joints).

The effects of pressure on the trigeminal nerve are periferrral effects (noxius input) afecting the CNS. Neuromuscular bite problems are also noxious input from the periferal nervous system.

A second article in Medical Hypothesis "Migraine, neuropathic pain and nociceptive pain: towards a unifying concept." brought this to light and pushed the unifying concept of mifgraine and neuropathic pain. The basic concepts are identical. Correction of noxious input is the key to treating the pain and preventing central sensitization. This is exactly the concepts behind Neuromuscular Dentistry.

This is also explained in an excellent article on Myofascial pain and TMD published in J Pain. 2009 Nov;10(11):1170-8 (see PubMed Abstract below)"Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing." that is interesting because it looks at a group of 20-28 year old patients with myofascial pain, TMD and central sensitization. This group of patients definitively show how periferral pain manifestations induce central sensitization. The time to intervene with neuromuscular dentistry is at an earlier stage before central sensitization occurs.

There is also a concern about the quality of sleep as TMD patients have a much higher incidence of sleep apnea which I believe predisposes patients to central nervous system changes. Migraines, Chronic Daily Headaches, Tension-Type headaches and TMD are all directly effected by the trigeminal nerve and the trigeminovascular connection. Neuromuscular Dentistry can effect the central nervous system by changing the quality of neuro input.

Med Hypotheses. 2010 Feb 19. [Epub ahead of print]

Atypical trigeminal neuralgia: A consequence of central sensitization?
Hu WH, Zhang K, Zhang JG.

Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.

Trigeminal neuralgia (TN) is characterized by sudden, recurrent, usually unilateral, severe brief stabbing pains in the distribution of trigeminal nerve. Although it is widely accepted that blood vessel or tumor compression contributes to paroxysms of TN, the pathogenesis of persistent background pain in atypical TN patient is unclear. Central sensitization is pain hypersensitivity caused by central neural plasticity. It is responsible for many temporal and symptomatic features of acute and chronic pain. We hypothesize that central sensitization might account for some symptoms of atypical TN. Based on this hypothesis, we postulate that early medical intervention predicts good outcomes in TN and medicines which are effective on central sensitization may be potential agents for the treatment of atypical TN. Copyright © 2010 Elsevier Ltd. All rights reserved.

PMID: 20172658 [PubMed - as supplied by publisher]

Med Hypotheses. 2010 Feb;74(2):225-31. Epub 2009 Sep 17.

Migraine, neuropathic pain and nociceptive pain: towards a unifying concept.
Chakravarty A, Sen A.

Department of Neurology, Vivekananda Institute of Medical Sciences, Calcutta, India. saschakra@yahoo.com

Migraine, neuropathic pain and nociceptive pain are the three commonest pain syndromes affecting human. In the present article, we first present the salient features of the pathophysiology of the three conditions particularly highlighting the core features that are similar in the three conditions. We argue on the validity of the prevailing concept that maintenance of structural integrity of the nervous system differentiates nociceptive pain from neuropathic pain and point out that the fundamental pathophysiology of lasting nociceptive pain (like cancer pain) and neuropathic pain (like nerve injury pain) is essentially same. Migraine pathophysiology is complex and complicated by two opposing views on site of migraine pain generation - peripheral versus central. We hypothesize that this dichotomy has resulted from focusing on two different sites on a single, somewhat complicated, pain mediating circuitry from the peripheral meningeal and vascular structures through several cell stations in the brain stem and thalamus up to the sensory cortical matrix. At the end, we suggest that fundamentally all the three pain syndromes referred to in the article share a common pathophysiological mechanism, namely peripheral pain perception, peripheral sensitization at dorsal root ganglion or its intracranial counterpart (like trigeminal ganglion) and central sensitization at the spinal cord (dorsal horn for somatic pain), brain stem nuclei and thalamus before final pain perception at the sensory cortical matrix.

PMID: 19765908 [PubMed - in process]
that cause central sensitization and pain.

J Pain. 2009 Nov;10(11):1170-8. Epub 2009 Jul 9.
Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing.

.
Fernández-de-las-Peñas C, Galán-del-Río F, Fernández-Carnero J, Pesquera J, Arendt-Nielsen L, Svensson P.

Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain. cesar.fernandez@urjc.es

Our aim was to investigate bilateral, widespread pressure-pain hypersensitivity in nerve, muscle, and joint tissues in women with myofascial temporomandibular disorders (TMD) without concomitant comorbid conditions. Twenty women with myofascial TMD (aged 20 to 28 years old), and 20 healthy matched women (aged 20 to 29 years), were recruited. Pressure-pain thresholds (PPT) were bilaterally assessed over supra-orbital (V1), infra-orbital (V2), mental (V3) nerves, median (C5), radial (C6) and ulnar (C7) nerve trunks, the C5-C6 zygapophyseal joint, the lateral pole of the temporo mandibular joint (TMJ), and the tibialis anterior muscle in a blinded design. The results showed that PPTs were significantly decreased bilaterally over the supra-orbital, infra-orbital, and mental nerves, median, ulnar, and radial nerve trunks, the lateral pole of the TMJ, the C5-C6 zygapophyseal joint, and the tibialis anterior muscle in patients with myofascial TMD as compared to healthy controls (all sites: P < .001). There were no significant differences in the magnitude of PPT decreases between the trigeminal and extratrigeminal test sites. PPT over the mental nerve, the TMJ, C5-C6 zygapophyseal joint and tibialis anterior muscle were negatively correlated to both duration of pain symptoms and TMD pain intensity (P < .05). Our findings revealed bilateral, widespread pressure hypersensitivity in women presenting with myofascial TMD, suggesting that widespread central sensitization is involved in myofascial TMD women. PERSPECTIVE: This article reveals the presence of bilateral and widespread pressure-pain hypersensitivity in women with myofascial TMD, suggesting that widespread central sensitization is involved in myofascial TMD. This finding has implications for development of management strategies.

PMID: 19592309 [PubMed - indexed for MEDLINE]

FACIAL PAIN AND NEUROMUSCULAR DENTISTRY

The diagnosis of facial pain is frequently not called headache pain and often receives a wrong diagnosis. Possible causes of facial pain are TMJ disordrs, trigeinal neuralgia, parotid gland disorders, masticatory muscle pain or pain referred from the cervical an shoulder reasons. Facial pain may resolve easily with neuromuscular dental treatment but it is important to rule out pain of organic nature.

Facial pain and sinus pain are frequently different terms patients use to describe pain referred from muscles which are the easiet pain a neuromuscular dentist treats.

When there is neuralgia pain it is usually sharp, sudden and lancinating and very emotionally charge. I have had patients with trigeminal neuralgia that will protect their trigger area no matter what. It is important to identify triggers that set off this type of excruciating pain. I have seen many patients over the years with neuralgia like pains. Some resonded well to neuromuscular dental treatment immediately while others responded to trigger point injections.

Frequently the area must be calmed down by drug therapy or counter irritants like capascin cream before attempting to place a patient on a TENS unit.