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.

Can Dentists Prevent Migraines? The Answer Is Yes According To New Research Out Of Germany.

The Journal of Neuroscience (J Neurosci. 2011 Feb 9;31(6):1937-43) recently published an article titled "Trigeminal nociceptive transmission in migraineurs predicts migraine attacks"

I have long advocated that the majority of Migraines and Tension-Type headaches are actually input-output errors. Nociceptive information entering the Trigeminovascular system are the pathology that triggers migraines and other headaches.

This study looked at fMRI or functional MRI studies of the brain.

They found that predicting migraine by trigeminal nociceptive activity could predict migraines.

Whers does most nociceptive trigeminal input arise?

In the Jaw Muscles, Muscle Spindles, Golgi Tendon Organs and periodontal ligaments of the teeth.

Neuromuscular Dentistry is very effective in eliminating and preventing migraines and muscular tension-type headaches. The majority of "sinus headaches" are actually referred muscle pain. The reason for the success of Neuromuscular Dentistry is the ability to eliminate nociceptive input.

Input/output errors are often described in computer lingo as Garbage In / Garbage Out.

The neurofeedback loops from periodontal ligaments , muscles, muscle spindles etc send nociceptive input (ie Garbage in) into the trigeminovascular system.

Migraines and other headaches are the "Garbage Out " part of the equation.
The article states that:
"Remarkably, the distance to the next headache attack was predictable by the height of the signal intensities in the spinal nuclei. Migraine patients scanned during the acute spontaneous migraine attack showed significantly lower signal intensities in the trigeminal nuclei compared with controls, demonstrating activity levels similar to interictal patients. Additionally we found-for the first time using fMRI-that migraineurs showed a significant increase in activation of dorsal parts of the pons, previously coined "migraine generator." Unlike the dorsal pons activation usually linked to migraine attacks, the gradient-like activity following nociceptive stimulation in the spinal trigeminal neurons likely reflects a raise in susceptibility of the brain to generate the next attack, as these areas increase their activity long before headache starts. This oscillating behavior may be a key player in the generation of migraine headache, whereas attack-specific pons activations are most likely a secondary event."

Another article in Neurology. 2011 Jan 18;76(3):206-7 states "Photophobia is an abnormal sensitivity to light experienced by migraineurs during attacks. The pathophysiology of photophobia is poorly understood. Nevertheless, 2 facts appear to have a link with photophobia: visual cortex hyperexcitability on the one hand and interactions between visual pathway and trigeminal nociception on the other."

The photophobia or sensitivity to light during a migraine attack is also due, in part to trigeminal nociception (Garbage in. The nociceptive input from the teeth,jaws, periodontal ligaments are the "garbage in" and the migraines and photophobia are the Garbage out".

Experimental studies on rats "J Neurosci. 2010 Oct 27;30(43):14420-9.
Changes of meningeal excitability mediated by corticotrigeminal networks: a link for the endogenous modulation of migraine pain." confirm the effect of trigeminanl nociception on meningeal migraines. The Trigeminovascular system is always paramount in migraine. The Trigeminal nerve controls the blood flow to the anterior 2/3 of the meninges of the brain.

Primary Stabbing Headaches are also trigeminally innervated as reported in"
J Headache Pain. 2011 Jan 6. [Epub ahead of print]
Incidence and influence on referral of primary stabbing headache in an outpatient headache clinic." The article states that "Primary stabbing headache (PSH) is a pain, as brief, sharp, jabbing stabs, predominantly felt in the first division of trigeminal nerve." The trigeminal nerve you will remember is the Dentist's nerve.


PubMed Abstract below:

J Neurosci. 2011 Feb 9;31(6):1937-43.
Trigeminal nociceptive transmission in migraineurs predicts migraine attacks.

Stankewitz A, Aderjan D, Eippert F, May A.

Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany.
Abstract

Several lines of evidence suggest a major role of the trigeminovascular system in the pathogenesis of migraine. Using functional magnetic resonance imaging (fMRI), we compared brain responses during trigeminal pain processing in migraine patients with those of healthy control subjects. The main finding is that the activity of the spinal trigeminal nuclei in response to nociceptive stimulation showed a cycling behavior over the migraine interval. Although interictal (i.e., outside of attack) migraine patients revealed lower activations in the spinal trigeminal nuclei compared with controls, preictal (i.e., shortly before attack) patients showed activity similar to controls, which demonstrates that the trigeminal activation level increases over the pain-free migraine interval. Remarkably, the distance to the next headache attack was predictable by the height of the signal intensities in the spinal nuclei. Migraine patients scanned during the acute spontaneous migraine attack showed significantly lower signal intensities in the trigeminal nuclei compared with controls, demonstrating activity levels similar to interictal patients. Additionally we found-for the first time using fMRI-that migraineurs showed a significant increase in activation of dorsal parts of the pons, previously coined "migraine generator." Unlike the dorsal pons activation usually linked to migraine attacks, the gradient-like activity following nociceptive stimulation in the spinal trigeminal neurons likely reflects a raise in susceptibility of the brain to generate the next attack, as these areas increase their activity long before headache starts. This oscillating behavior may be a key player in the generation of migraine headache, whereas attack-specific pons activations are most likely a secondary event.

PMID: 21307231 [PubMed - indexed for MEDLINE]


Neurology. 2011 Jan 18;76(3):213-8. Epub 2010 Dec 9.
A PET study of photophobia during spontaneous migraine attacks.

Denuelle M, Boulloche N, Payoux P, Fabre N, Trotter Y, Géraud G.

Service de Neurologie et Explorations Fonctionnelles du Système Nerveux, CHU Rangueil, Toulouse, France. denuelle.m@chu-toulouse.fr

Comment in:

* Neurology. 2011 Jan 18;76(3):206-7.

Abstract

BACKGROUND: Photophobia is an abnormal sensitivity to light experienced by migraineurs during attacks. The pathophysiology of photophobia is poorly understood. Nevertheless, 2 facts appear to have a link with photophobia: visual cortex hyperexcitability on the one hand and interactions between visual pathway and trigeminal nociception on the other.

METHODS: We used H(2)(15)O PET to study photophobia induced by continuous luminous stimulation covering the whole visual field in 8 migraineurs during spontaneous migraine attacks, after headache relief by sumatriptan and during attack-free interval. The intensity of the luminous stimulation provoking photophobia with subsequent headache enhancement was specifically determined for each patient.

RESULTS: We found that low luminous stimulation (median of 240 Cd/m(2)) activated the visual cortex during migraine attacks and after headache relief but not during the attack-free interval. The visual cortex activation was statistically stronger during migraine headache than after pain relief.

CONCLUSION: These findings suggest that ictal photophobia is linked with a visual cortex hyperexcitability. The mechanism of this cortical hyperexcitability could not be explained only by trigeminal nociception because it persisted after headache relief. We hypothesize that modulation of cortical excitability during migraine attack could be under brainstem nuclei control.

PMID: 21148120 [PubMed - indexed for MEDLINE]

J Neurosci. 2010 Oct 27;30(43):14420-9.
Changes of meningeal excitability mediated by corticotrigeminal networks: a link for the endogenous modulation of migraine pain.

Noseda R, Constandil L, Bourgeais L, Chalus M, Villanueva L.

Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02215, USA.
Abstract

Alterations in cortical excitability are implicated in the pathophysiology of migraine. However, the relationship between cortical spreading depression (CSD) and headache has not been fully elucidated. We aimed to identify the corticofugal networks that directly influence meningeal nociception in the brainstem trigeminocervical complex (Sp5C) of the rat. Cortical areas projecting to the brainstem were first identified by retrograde tracing from Sp5C areas that receive direct meningeal inputs. Anterograde tracers were then injected into these cortical areas to determine the precise pattern of descending axonal terminal fields in the Sp5C. Descending cortical projections to brainstem areas innervated by the ophthalmic branch of the trigeminal nerve originate contralaterally from insular (Ins) and primary somatosensory (S1) cortices and terminate in laminae I-II and III-V of the Sp5C, respectively. In another set of experiments, electrophysiological recordings were simultaneously performed in Ins, S1 or primary visual cortex (V1), and Sp5C neurons. KCl was microinjected into such cortical areas to test the effects of CSD on meningeal nociception. CSD initiated in Ins and S1 induced facilitation and inhibition of meningeal-evoked responses, respectively. CSD triggered in V1 affects differently Ins and S1 cortices, enhancing or inhibiting meningeal-evoked responses of Sp5C, without affecting cutaneous-evoked nociceptive responses. Our data suggest that "top-down" influences from lateralized areas within Ins and S1 selectively affect interoceptive (meningeal) over exteroceptive (cutaneous) nociceptive inputs onto Sp5C. Such corticofugal influences could contribute to the development of migraine pain in terms of both topographic localization and pain tuning during an attack.

J Headache Pain. 2011 Jan 6. [Epub ahead of print]
Incidence and influence on referral of primary stabbing headache in an outpatient headache clinic.

Guerrero AL, Herrero S, Peñas ML, Cortijo E, Rojo E, Mulero P, Fernández R.

Neurology Department, Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain, gueneurol@gmail.com.
Abstract

Primary stabbing headache (PSH) is a pain, as brief, sharp, jabbing stabs, predominantly felt in the first division of trigeminal nerve. Population studies have shown that PSH is a common headache. However, most people suffer attacks of low frequency or intensity and seldom seek for medical assistance. There are few clinic-based studies of PSH, and its real influence as a primary cause for referral to neurology outpatient offices is to be determined. We aim to investigate the burden of PSH as main complaint in an outpatient headache clinic. We reviewed all patients with PSH (ICHD-II criteria), attended in an outpatient headache clinic in a tertiary hospital during a 2.5-year period (January 2008-June 2010). We considered demographic and nosological characteristics and if PSH was main cause of submission. 36 patients (26 females, 10 males) out of 725 (5%) were diagnosed of PSH. Mean age at onset 34.1 ± 2.9 years (range 10-72). Mean time from onset to diagnosis 68.8 ± 18.3 months. Twenty-four patients fulfilled ICHD-II criteria for other headaches (14 migraine, 6 tension-type headache, 2 hemicrania continua, 1 primary cough headache and 1 primary exertional headache). 77.7% of patients were submitted from primary care. In 14 patients (39%), PSH was main reason for submission, its intensity or frequency in 5 (35.7%) and fear of malignancy in 9 (74.3%). Only two patients of those who associated other headaches were submitted due to PSH. In conclusion, PSH is not an uncommon diagnosis in an outpatient headache office. However, and according to our data, it is not usually the main cause of submission to a headache clinic.

PMID: 21210176 [PubMed - as supplied by publisher]

What is Neuromuscular Dentistry? I Hate Headaches.org has the answers.

This website is all about utilizing neuromuscular dentistry to treat and prevent migraines and tension type headaches.

I invite you to roam the site and follow the links to learn how the teeth, jaws and jaw muscles along with the trigeminal nerve are partially or completely connected to chronic pain. Neuromuscular dentistry can help a wide variety of chronic pains, treat sleep apnea and snoring, possibly alleviate sympoms of movement disorders including Parkinson's.

Visit Sleep and Health Journal (http://www.sleepandhealth.com/neuromuscular-dentistry) for my detailed article on Neuromuscular Dentistry that was first published by the American Equilibration Society and the republished in ICCMO's annual anthology of Neuromuscular Dentistry.

Learn why TMJ disorders are called The Great Imposter in another Sleep and Health Journal article. http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor

TENSION-TYPE HEADACHES AND MIGRAINES OFTEN HAVE COMMON CO-MORBIDITIES OF TEMPOROMANDIBULAR DISORDERS, MYOFASCIAL PAIN AND FORWARD HEAD POSITION

A new article "Pure tension-type headache versus tension-type headache in the migraineur." in Curr Pain Headache Rep. 201:465-9.0 Dec;14(6) (PubMed abstract below) looks at primary headache disorders. What is most interesting is that they state that differential diagnosis is made difficult to the frequent presence of co-morbidities including temporomandibular disorders and myofascial pain.

I wish the authors could realize that what they classify as co-morbidities are actually underlying triggers and causes of both migraines and tension-type headaches. When they assume that these headaches are primary they miss the opportunity to actually treat and prevent them from occuring. The authors go on to state "chronification, particularly of migraine, leads to a decrease in the associated symptoms of migraine, such as nausea, photophobia, and phonophobia, so that these headaches more closely resemble tension-type headache" and missing the fact that central sensitiztion and chronicity is due to not treating the primary trigeminal nerve problem that is secondary to repetitive motion injuries from underlying dysfunction that leads to myofascial pain disorders.

There is a musclar component as well as a neurogenic/vascular component to all headaches. The real issue is the elimination of the conditions that trigger tension-type headaches, migraines and TMJ (TMD) disorders. Neuromuscular dentistry is extremely effective in preventing and eliminating tension-type headaches and migraines because it eliminates the repetitive strain injuries by idealizing the physiologic status of the entire trigeminal nervous system that is responsible in whole or in part for almost all migraines and tension-type headaches as well as other head, neck and facial pain.


Curr Pain Headache Rep. 201:465-9.0 Dec;14(6)
Pure tension-type headache versus tension-type headache in the migraineur.
Blumenfeld A, Schim J, Brower J.
The Headache Center of Southern California, 320 Santa Fe Drive, Encinitas, CA 92024, USA. blumenfeld@neurocenter.com
Abstract
Primary headache disorders include tension-type headache and migraine. These headache types can be differentiated based on strict clinical definitions that depend on the patient's signs and symptoms. However, some of the clinical features can overlap, and in addition, the same comorbid conditions can occur in both headache types. Distinction between these headache types on occasion can be difficult due to comorbid conditions such as temporomandibular joint disorders and myofascial pain with forward head posturing, which may be present in both headache disorders, and thus result in similar features in both conditions. Furthermore, chronification, particularly of migraine, leads to a decrease in the associated symptoms of migraine, such as nausea, photophobia, and phonophobia, so that these headaches more closely resemble tension-type headache. Finally, in some patients, both tension-type headache and migraine may occur at different times.
PMID: 20878271 [PubMed - in process]

WHAT IS THE BEST TMJ TREATMENT?

THERE IS NO SINGLE "BEST TREATMENT" FOR TMJ BECAUSE TMJ IS NO A SINGLE DISEASE OR PROBLEM. TMJ actually stands for TemporoMandibular Joint and it is a joint not a disease. Everyone has two TM Joints. TMD stands for TemporoMandibular Dysfunction but it is also a general term.

The following should help guide patients in finding the "right " doctor.

To receive the "Best TMJ Treatment" it is first necessary to have the "Best TMJ Diagnosis".

The diagnosis is actually the most complex part of treating this group of disorders.

The medical SOAP model is an essential part of arriving at the right diagnosis and treatment and is frequently not followed.

The "S" in SOAP is the subjective findings. These come from the patients history. Many dentists and physicians short change patients by not getting a thorough and complete history. Often, relevant facts about a patient's history are missed or revealed later by patients. I usually set aside a minimum of one hour for a first visit with a patient with chronic pain. My team will often schedule much longer appointments when a case appears complicated. The tentative diagnosis or diagnostic tree (differential diagnosis) is made from the patient's history and interview. It is the confirmed or reevaluated based on Objective findings.

The "O" in SOAP is the objective findings. Before objective testing is done the subjective history helps determine the proper testing that is appropriate for each patient. Objective testing includes Radiographs or x-rays. These may be plain film, cone beam, CT scans, MRI's. These are used to diagnose bony changes and soft tissue changes to the joints.

There are specific objective testing that helps determine the "Best TMJ Treatment" and confirms details of the working diagnosis. Neuromuscular Dentists use the following diagnostic tools to elucidate the complete nature of this disorder.

THE FOLLOWING OBJECTIVE DEVICES ARE USED BY NEUROMUSCULAR DENTISTS TO AID IN DIAGNOSIS AND TREATMENT OF CRANIOMANDIBULAR DISORDERS (TMJ, MPD, MPD,ETC)

EMG or Electromyography that is used to determine starting levels of muscle activity, symmetry of muscle activity, funCtional activity as it relates to posture and function. Spectral Analysis of EMG help to determine underlying physiologic sTatus of the muscles. EMG can also be used to fine tune bite corrections and to measure efficacy of treatment.

Sonography and/or JVA (joint vibration analysis) Can be used to measure the health of the joint and determine thru spectral analysis the amount of joint damage or changes.

MKG (mandibular kinesiograph) , CMS (computerized Mandibular Scans) are used to evaluate function and movement and in conjunction with ULF TENS to measure rest position.

ULF TENS is used diagnostically and as a treatment tool. The the dimensional position of the jaw is evaluated before and after muscle relaxation (as confirmed by EMG)

Blood Tests, urine chemistry, thyroid function are all objective tests that are used when appropriate. Sleep studies are an often under utilized diagnostic tool in finding the "BEST TMJ TREATMENT". Patients with morning headaches, snoring, high blood pressure and excessive daytime sleepiness should always be evaluated with polysomnography. The NHLBI (National Heart Lung and Blood Institute) of the NIH (National Institute of Health) considers Sleep Apnea to be a TMJ disorder.

Psychometric tests are also objective tests that are used in diagnosis. Unfortunately, many doctors believe that there are no real physical ailments and the TMJ is a "psychco-social" disease to be treated with drugs and psychotherapy. There are frequently psycho-social overlays to TMJ problems. Being in chronic pain changes patients in many ways. Psychometric testing often reveals the results of chronic pain rather than the cause.

The "A" in SOAP is the assessment, where all of the subjective and objective information allows the doctor to have a "working diagnosis" and to lay out an initial treatment plan.

The "P" in Soap is the PLAN or methods determined by the Physician or Dentist to be used to treat the patient. This may include use of medications, therapy or diagnostic orthopedic appliances. Many patients need numerous methods of treatment to address the disorders and problems diagnosed and revealed in Subjective and Objective examination. Frequently more than one practitioner will be involved in treatment.


DIAGNOSIS DOES NOT END WHEN A NEUROMUSCULAR DIAGNOSTIC ORTHOTIC IS PLACED IN A PATIENTS MOUTH!

It is essential to understand that diagnosis and treatment is an ongoing procedure and that a SOAP approach is used at subsequent appointments. The "BEST TMJ TREATMENT" is ongoing and as the patients improve it is frequently appropriate for the focus of treatment to change. It is important for the patient and doctor to be open and honest to achieve the best results.

I strongly believe that the Neuromuscular Dentistry approach is the best "TMJ" treatment but it is only a part of the total diagnosis.

My Headaches are throbbing, nausea, stabbing ....Renee

Heeadaches related to the trigeminal nerves and jaw function frequently have all of those qualities. This relates to the vascular, hemodynamic and autonomic functions of the trigeminal nerve. Neuromuscular dentistry can frequently allieve and eliminate these sypmtoms as well as the more common tender, aching, and penetrating headaches. Painful TM Joint symptoms may or may not be present.

TMJ Treatment: Is Neuromuscular Dentistry the TMJ Treatment?

Neuromuscular Dentistry treats TMJ disorders by correcting the underlying problems rather than just treating the symptoms. The old fashioned mechanical approach to TMD treatment only addresses the current symptoms. Long term correction of chronic headaches, joint pain and muscle pain is actually the result of healing when underlying pathology is eliminated. Neuromuscular Dentistry is the best way to correct function and permit long term healing.