By Harold Gelb, DMD
In dentistry as in medicine, the diagnosis and treatment of the chronic pain patient is one of the most difficult problems facing the clinician. This is partly due to the emphasis in our undergraduate and postgraduate training on primarily dealing with acute pain patients. Furthermore, the teeth and their supporting structures was the main part of our focus.
Today, as a result of changes in the direction of our approach to these patients, we have enlarged our horizons to now include in our diagnosis a triad approach which would include the teeth and their supporting structures, the maxilla and the mandible, muscular, nervous, and vascular systems, as well as the structures within each temporomandibular joint. This triad is not an entity in itself, but bears an important relation to the rest of the organism.
Most of the patient's symptoms would not usually direct them to the dentist as the primary health provider. Furthermore, most physicians do not recognize craniocervical mandibular disorders — part of the new classification system at one of our local dental schools — as a disease because it was never taught to them. Consequently, they do not include it in a differential diagnosis.
Much of this is quite surprising since chronic pain in the U.S. is a 60- to 90-billion-dollar-a-year industry of which 40 percent is spent on the head and face. It is estimated there are 50 million headache sufferers. The International Headache Society has allocated two of 13 headache types to the dentist — tension-type headache and headache or facial pain associated with a disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures. Headaches break down into three major categories — 2 percent are traction and inflammatory, 8 percent are vascular, and 90 percent are muscle contraction-tension type headaches that the dentist can help. Another group of symptoms that can be helped by dentists is tinnitus and vertigo, where the number of patients is in the multimillions.
In obtaining and maintaining a normal craniocervical mandibular articulation, it is necessary that the system as a whole and its constituent parts should be capable of adaption. The bony parts of the masticatory system may well be unrelated in size, the spaces not compatible with mandibular movement, and the teeth themselves too large or small. These genetic variations will affect individuals differently, and because adaption is a function of tissue behavior and of learning ability, the dental apparatus will work better in some individuals than in others. Function continues despite loss or damage, but there is considerable variation as how much the system can tolerate before showing signs of being overloaded by exhibiting other dysfunctional states. The latter may be gross attrition, and generalized traumatic effects in association with periodontal disease, breakdown and drifting of unsupported teeth, or degenerative joint changes. The occurrence of these illustrates that adaptive physiological limits have been exceeded and the weakest part of that particular masticatory system has been broken down. In some patients, it may be the periodontal tissues; in others it may be either the muscles or the joints.
Craniomandibular disorders are characterized by tenderness in the muscles attached to the jaws, head, neck, and back; painful temporomandibular joints with limited movement; joint noises; double and blurred vision; loss of balance and facial deformities. Headache, earache, neckache, and toothache are frequently listed as complaints. Presently, these disorders may be divided into categories (see page xx).
Taking a thorough medical, dental, and craniomandibular history, coupled with a comprehensive clinical examination, will still prove to be the most effective approach to diagnosing the patient's condition.
Some diagnostic tests and observations can be useful in making a preliminary diagnosis of a temporomandibular disorder. One is to palpate the joints laterally with significant pressure and have the patient open his or her mouth. If the patient complains of pain, this indicates injury or irritation in the joint proper. Another very crucial test is to place the pinky finger into the patient's right and left external auditory meatus and have the patient open and close. Many patients will not be able to close down on their back teeth without pain. There will be clicking felt on closure, as well as feeling crepitus. This, coupled with joint radiographs and model analysis on a three-dimensional basis, gives the dentist verification of orthopedic imbalance. Joint sounds also indicate pathosis. Placing a stethoscope over the joints can disclose sounds as the patient opens and closes his or her mouth. A crepitus or grating sound denotes in some mandibular movement that there may be a tear in the meniscus or disk. This is an important sign, indicative of an osteoarthritic change.
Many people with this problem suffer from a myofascial pain dysfunction syndrome, primarily as a muscular problem related to dental or skeletal malrelationships and tensional factors. There may be an irritation in the joint, but it most likely is reversible. This can be treated by moist heat, soft diet, muscle relaxants, dental splints, equilibration, and other procedures. The remaining individuals may have organic disease within the joint, as well as musculature and emotional factors. Most patients will be treated nonsurgically. Those with organic problems may require some type of surgery but, if properly diagnosed and treated, that percentage will be low.
Our first goal in the therapeutic chain of events is the positive assurance that the patient can be helped. This improves with time and experience. The interrelationship of jaw position, muscle spasms, myofascial trigger points, and the concept of referred pain from muscles of mastication, suprahyoids, infrahyoids, and the pre- and postvertebrae muscles is discussed with the patient as well. The concept of the stomatognathic triad is also discussed.
Therapy begins with eliminating pain. At first, we use palliative procedures, including moist heat, ultrasonic therapy, high-frequency currents, vapocoolant spray with stretch, exercise, tens, and non-steroidal anti-inflammatory medications.
Sometimes palliative procedures, in combination with psychological counseling, stress management, and relaxation therapy will alleviate symptoms. However, in more severe cases, where there has been long-standing tissue alteration in combination with a genetic predisposition, more aggressive treatment may be required.
In cases with temporomandibular joint pain and joint clicking, associated with myofascial disease, orthopedic therapy may be necessary. Until this orthopedic imbalance is corrected, there is usually no lasting relief.
Advanced training programs have already been initiated at several universities, many leading to master's and doctorate programs. This advanced training already includes neuroscience, radiology, physical medicine, pharmacology, psychology, and pain-control modalities.
At the present time, the magnitude of this disease entity has not been fully realized by all parties involved. The unhappy state of the individual suffering from this disease is by no means confined just to the patient, but also includes family and friends. There is sufficient proof that craniocervical mandibular disorders, to some measure, create anxiety states, and vice versa, although this is not the whole picture. We must logically conclude that the condition will become more common as civilization becomes more advanced and mechanized, or when we are unable to adapt to changes in our environment. Softer diets, poor nutrition, and reduced breast-feeding will increase malocclusion and alter morphology in the population. This will increase the incidence of craniocervical mandibular disorders.
Click here to view the NYU's orofacial pain & TMD diagnostic classification.
Dr. Harold Gelb is an adjunct professor in the department of general dentistry at Tufts University and maintains a private practice in New York City. He can be reached by phone at (212) 752-1661.