Whether it is in the internal organs, brain, muscles, or joints – dealing with persistent inflammation is an ongoing problem. Once inflammation is invested in the TMJs, neck, or jaw muscles, it often defines pain and suffering for the orofacial pain sufferer for extended periods of time.
Although inflammation is the initial step in the healing process unless the source of tissue injury or overuse is identified, it no longer has a useful purpose.
At my practice, we commonly see 3 types of patients, each of whom suffers from pain that has some, if not all, of its origins in inflammation. Each patient type, however, is rather different.
Patient Type 1: These patients are typically in trouble with tissue inflammation that is the end result of excessive mechanical overload of the muscles in the head, neck, and jaw as a result of overuse postures and acquired behaviors.
As excessive levels of lactic acid and other irritating by-products of muscle metabolism accumulate, an inflammatory soup develops, which leads to lowered pain thresholds and pain that is often out of proportion to the level of true tissue injury. Often these overuse behaviors or postures have been present for years with no pain outcomes and, as a result, are not viewed as problematic.
At times, however, when these patterns of muscle overuse exceed adaptive capabilities or are coupled with fragmented sleep, insufficient sleep, or ongoing brain upset due to unresolvable life events or emotional conflicts, the body’s pain-suppressing systems falter. With lower pain thresholds even well-conditioned muscles begin to ache and joints follow shortly.
Treatment must, therefore, focus on identifying the overuse patterns (i.e. daytime clenching, nail and cuticle biting, computer postural strain, jaw bracing without tooth contact, etc.) and getting the patient to participate in the process of eliminating or reducing them as quickly as possible. Once identified, the possibility of tissue healing becomes a reality with subsequent diminishment or elimination of symptoms.
Patient Type 2: These are the patients that have significant anatomical compromise of one or both of their TM joints leading to mechanical instability and associated inflammation.
The onset could be following a single eating event such as biting into an unexpectedly hard food item or the result of longstanding TM joint clicking that progressed to locking and pain. The pain typically reflects the presence of inflammation then prompts muscle guarding and bracing in the masseter, temporalis, and trapezius muscles. Unfortunately, once the inflammation drives the muscles into this state of contracture, the only way out is to resolve the joint inflammation. This is not necessarily easy.
A combination of non-steroidal or steroid medications used orally for long or short periods of time respectively, along with oral appliances, diet modifications, physical therapy, and ice applications daily often are sufficient to get the job done.
Less commonly, but often necessary, is the need to inject steroid into the inflamed joint. With all small joints, however, there is a small therapeutic window that needs to be respected with regard to which steroid is chosen, how much is injected, and how frequently can it be done. Despite these concerns, the injectable steroid still has its place and when coupled with Botox injections in the ipsilateral masseter and temporalis muscle appears to have greater efficacy. The consideration of PRP injections is gaining some traction, as well, but is not a predictable option at this point in time.
Beyond these options, if inflammation persists, the need to look at surgical options inclusive of an arthrocentesis, arthroscopic, or open joint surgery to address the joint pathology becomes the next choice.
Once the inflammation is ultimately addressed, muscle comfort will follow.
Patient Type 3: These patients, though with the least amount of observable tissue injury, are the most challenging to treat. The orofacial pain they typically report is often just one of a number of pain problems they live with on a daily basis.
The presence of other pain associated with an irritable bowel, migraine headaches, or chronic back and neck muscle pain is often noted in the medical histories of these patients. Whether the origins are genetic, epigenetic (environmentally induced) or due to life traumas and the resultant PTSD (domestic issues) – chronic muscle tension is the result. Inflammation sets in and pain emerges.
Examination findings reveal painful, but full masticatory function. In fact, the level of patient suffering appears excessive of the physical findings. These patients are, in essence, suffering from what has been called neurogenic inflammation, which has a neuroimmune basis involving microglial cells, which when “stressed”, have the ability to amplify inflammation and pain signals to the brain – even when tissue injury is limited or not even present.
Predicting a level of treatment success and aligning patient expectations with the likely outcomes of care is the most challenging aspect of this patient encounter. The ultimate goal is symptom reduction, which often requires multiple levels of care. Medications considered include nortriptyline/amitriptyline and may include low dose naltrexone (LDN), which has found promise in treating fibromyalgia and Crohn’s disease along with persistent trigeminal pain problems due to its ability to decrease microglia excitation. We also encourage Tai Chi as a way to pursue essential daily exercise, all forms of meditation, and specific diaphragmatic breathing programs. Patient participation is essential.
Clearly, these three patient populations require identification and ultimately specific treatment strategies. It all starts with knowing who your patient is…