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Orofacial Pain

Orofacial Pain is the specialty of dentistry that encompasses the diagnosis, management andtretment of pain disorders of the jaw, mouth, face, head and neck.

An Orofacial Pain specialist must be educationally qualified by completion of an educational program of two or more years accredited by the Commission on Dental Accredtation (CODA) of the American Dental Association and board certification by the American Board of Orofacial Pain.  

The most common pain in the mouth is dental pain. The most common pain in the face is muscle pain. When an obvious cause is not present, pains are generally classified as: neuropathic pains (related to nerves, such as a neuralgia), neurovascular pains (related to nerves and blood vessels, such as a migraine) and musculoskeletal pains (related to muscle and joints, such as TMJ and neck problems). The following information summarizes these types of disorders, their origins and symptoms.

Neuropathic Pain

Neuropathic pain refers to pains originating in the central (brain and spinal cord) or peripheral (nerve fibers) nervous system. Most of us are familiar with an injured body part sending signals along a healthy nerve to tell us that the body part hurts. In neuropathic pain, the problem lies within the nerve itself, telling us that a healthy body part hurts. Therefore, it can be very frustrating for a patient experiencing severe pain while everything appears to be healthy. Neuropathic pains are often accompanied by complaints of burning, stinging or shocking sensations, and sometimes mechanical complaints, such as intense squeezing or pulling.

In some cases, neuropathic pain may develop after a dental procedure cuasing confusion for the dentist and the patient. 

Neuralgia refers to pain along the distribution of a nerve. Trigeminal neuralgia is a unique type of nerve pain with specific characteristics. The facial pain is characterized by spontaneous, brief episodes of electric shock-like pains limited to the distribution of the involved branch of the nerve. Pain may be triggered by light touch in a " trigger zone" usually along the same nerve distribution as the pain. It may also occur spontaneously. The paroxysms (volleys) of pain usually last from seconds to minutes.

The trigeminal nerve is the major sensory nerve to the face and head. It has three branches and the pain may be in one or more branches of the nerve. Most often the pain is on one side of the face only. 

Many neuralgias exist and may be named for the involved nerve such as glossopharyngeal neuralgia (one of the sensory nerves of the tongue and throat) or occipital neuralgia (a sensory nerve at the base of the skull and back of the head). It is important to note is that two forms of neuralgias exist: paroxysmal (episodic) and continuous. Paroxysmal neuralgias are intense, often electric, pains that come in brief volleys (seconds to minutes in duration). An example of a paroxysmal neuralgia is trigeminal neuralgia, which is described above.

Continuous neuralgias are usually less intense and are often described as constant burning and aching, sometimes with episodic shooting pains. An example of a continuous neuralgia may follow shingles and is called post herpetic neuralgia. Continuous neuralgias may be extremely difficult to diagnose and treat, as many causes can be responsible for the nerve dysfunction. In contrast to paroxysmal neuralgias, continuous neuralgias in the head and face may affect both sides of the head and face. Characteristic of continuous neuralgias is that the site of pain often involves a larger area than the distribution of the involved nerve. Frequently patients complain of extreme sensitivity to touch or temperature, and their pain may be much worse than one would expect from an obvious injury. 

Continuos or episodic neuralgias can occur after dental treatments. 

In some cases of neuropathic pain, different medications or combinations must be tried. Continuous neuralgias may respond to different medications than those prescribed for paroxysmal neuralgias. Sometimes procedures such as nerve blocks are needed to treat the problem.

Neurovascular Pains

Primary headaches are headaches that have no other known cause for the pain such as fever, trauma or tumor. The most common primary headaches are migraine and tension type headaches.

Migraine is a type of headache often described as a "sick headache" because it is accompanied by nausea and sometimes vomiting as well as the need to lie down, usually in a dark environment. The headaches usually last from 4 to 72 hours. Many people also report sensitivity to both light and sound with a migraine headache. Some patients (approximately 20%) will experience an aura before the headache that often presents as flashing or moving lights. Auras last 10-30 minutes and may also present with frightening symptoms such as numbness or even speech problems.
Many types of headaches exist and vary according to the cause, such as illness, trauma or tumor. Recently, a new onset headache or worsening of an exsisting headache has been reported with COVID-19.

Musculoskeletal Pains

These terms are often used interchangeably but are quite different. The term TMJ refers to the Temporomandibular Joint. This term is often incorrectly used to describe disorders of the temporomandibular joint and associated structures. The TMJ is the joint between the lower jaw, or mandible, and the temporal bone of the skull. TMD stands for Temporomandibular Disorders which includes all disorders of the jaw muscle, jaw joint or both. 
There seems to be many factors that lead to TMDs and these will vary from individual to invidual. The old theories of poor bite relationships and improper jaw position have been disproven in multiple studies. An orofacial pain specialist will be able to help you identify potential causes and guide you to the most appropriate care.
It is important to understand that most TMDs can be treated with very conservative and non invasive care. TMDs are not necessarily progressive. Aggresive therapies that involve bite adjustments, jaw repositioning and the use of awake time oral appliances are not supported by the science. In many cases, simple self care modalities like changing jaw function behaviors can be quite effective.
Botulinum toxin (Botox©) has been shown to help manage some of the pain associated with TMDs in some of individuals. Contrary to what some advertise, it should not be considered a cure for TMDs. Scientific studies have shown that Botox© does not stop teeth grinding nor stop all muscle activity. Even though it is injected into muscles, the main effect seems to be in the central nervous system. The effects of Botox© have been shown to last for approximately 3 months. For this reason, it should be viewed as an adjunctive treatment to be used in combination with a comprehensive treatment plan.
The term bruxism refers to the clenching or grinding of the teeth. The activity can occur during sleep or while awake and should be considered as two different entities. Awake time activity is more of a habit and can be controlled by self awareness. Sleep activity occurs due to unconcious activity in the brain similar to other sleep movements. Many individuals will have periodic episodes of grinding their teeth during sleep with no negative consequences. Contrary to a popular belief, bruxism is not caused by a "poor bite relationship".
Studies have shown that certain types of TMD may improve with the use of an intraoral appliance. These devices are thought to decrease the load or force placed on the jaw joints and muscles when worn. Although many different forms of appliances are available with claims of success, most will have similar therapeutic effects. Awake time use of oral applainces as well as the use of devices designed to establish a so called "ideal bite realtionship" should be avoided. An accurate diagnosis along with an appropriate and multi-disciplined approach to therapy is the key for success of any treatment approach. No two individuals are the same so treatment should be individualized for each patient.
Only approximately 5% of patients with temporomandibular disorders require a surgery consult. Surgery should only be considered only after more conservative therapies have failed to resolve the primary problem. Surgery should never be considered as the primary means of resolving pain. Surgery is considered when a specific diagnosis is known that cannot be adequately treated without surgery. One example might be a tumor in the jaw joint.
Braces, or orthodontics are considered to be "TMD neutral". This means that research has failed to prove that braces either causes or helps TMDs. Also, orthodontic therapy has not been shown in research to prevent the onset of TMDs.
Many years ago it was felt that temporomandibular disorders were related to a bad bite or jaw position. Over the years these theories have been mostly disproven. Bite altering therapies should not be the first choice for treating TMDs. In fact, a change in the bite relationship may cause the onset or worsening of some patients symptyoms.
There are many in dentistry that will make the claim of being a "TMJ Specialist". Orofacial Pain Specialist are  dentists that are educationaly trained in 2 year university post graduate programs and board certified in the diagnosis and management of temporomandibular disorders (TMDs) by the American Board of Orofacial Pain. A general dentists and most other dental specialists are not qualified to claim to be a "TMJ specialist".