Because of the complex anatomy and specialized sensory innervation of the head and neck, craniofacial pain disorders merit special consideration. Many craniofacial syndromes are unique and represent a clinical diagnostic challenge. This chapter presents an introduction to practical issues regarding assessment and treatment of common craniofacial pain disorders in accordance with the diagnostic classification scheme of the International Headache Society (IHS) ( Boxes 31.1 to 31.3 ).
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14 Categories
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Primary headaches: 1-4
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Secondary headaches: 5-12
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Cranial neuralgias, central and primary facial pain, and other headache disorders: 13-14
11.2—Neck
Cervicogenic headache
11.3—Eyes
Acute glaucoma
Latent or manifest squint
Ocular inflammatory disorders
11.5—Sinus disorders (“sinus headache”)
11.6—Teeth, jaws, or related structures
11.7—Temporomandibular joint disorders
13.1—Trigeminal neuralgia
13.2—Glossopharyngeal neuralgia
13.3—Nervus intermedius neuralgia
13.4—Superior laryngeal neuralgia
13.5—Nasociliary neuralgia
13.6—Supraorbital neuralgia
13.7—Other terminal branch neuralgias
13.8—Occipital neuralgia
13.9—Neck-tongue syndrome
13.12—Constant pain caused by compression, irritation, or distortion of cranial nerves or upper cervical roots by structural lesions
13.13—Optic neuritis
13.14—Ocular diabetic neuropathy
13.15—Head or facial pain attributed to herpes zoster post-herpetic neuralgia
13.16—Tolosa-Hunt syndrome
13.17—Ophthalmoplegic “migraine”
13.18—Central causes of facial pain
Anesthesia dolorosa
Central post-stroke pain
Facial pain attributed to multiple sclerosis
Persistent idiopathic facial pain
Burning mouth syndrome
Pain Caused by Pathology of the Head, Face, and Oral Cavity
The specialized structures of the head and face have a rich sensory innervation supplied by the trigeminal system, lower cranial nerves, and upper cervical roots. Accordingly, pain is one of the most prominent symptoms of disease in this area. In most cases the acute pain symptoms closely correlate with other signs and symptoms of disease. However, correlation between pain and other symptoms may not be evident in a number of more complex, chronic pain problems, particularly those involving the masticatory system.
Dental Pain
Tooth pulp has a specialized and possibly exclusively nociceptive innervation. In contrast, periodontal tissues are innervated by a wide variety of sensory afferents. Dentin and pulp are closely related and function as a unit. In other words, all procedures performed on dentin are essentially performed on dentin and pulp, the pulpodentinal complex.
Dental pain is usually well localized, and the quality of the pain can range from a dull ache to severe electric shocks, depending on the specific etiology and extent of disease ( Box 31.4 ). Dental pain is typically provoked by thermal or mechanical stimulation of the damaged tooth. Clinical and radiographic findings of dental decay, tooth fracture, or abscess drainage may confirm the source of dental pain.
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Dentoalveolar pathology
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Pulpal
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Periodontal
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Odontogenic and nonodontogenic pathology
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Trigeminal neuralgia and “equivalents”
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Headache and neck pain
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Temporomandibular disorders
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Oral mucous membrane disease
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Oral manifestations of systemic disease
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Neuropathic pain (persistent idiopathic facial pain)
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Burning mouth/tongue syndrome
Dentin Sensitivity
Exposed dentin (open cavities, exposed cervical dentin) is markedly sensitive to changes in temperature, to touch, and to sweets. When exposed, dentin is stimulated (cold, sweet, touch); a sharp pain of short duration is experienced immediately following stimulation. “Conduction of pain” through dentin has received quite a lot of attention both clinically and in research. Treatment of sensitive dentin has attracted the attention of industry, and quite a few products are commercially available. Through the years, hundreds of methods have been advocated for the treatment of sensitive dentin, thus showing that no method is really effective.
Pulp Inflammation and Pain
The duration of pain is commonly used as a clinical yardstick for determining whether the symptoms are caused by sensitive dentin or pulp inflammation. If a cold test results in pain that lasts for a few seconds, the cause is considered to be sensitive dentin. Lingering pain is taken as an indication of pulp inflammation. This clinical yardstick is crude and inexact, but no better method exists. So if the pain lasts beyond seconds or lingers when the stimulus is removed, it is considered an indication for endodontic intervention. Pulp inflammation as a result of dental caries (decay) needs to be treated surgically and medically with routine dental restorative or endodontic therapy (or both).
Pulp inflammation, if left untreated, will spread apically and the inflammatory process will extend outside the apical foramen. Therefore, in the late stages of pulp inflammation, there is no border between pulp and periapical inflammation, and symptoms from the two types of processes can be mixed.
Periapical Inflammation and Pain
Bacterial by-products seep out through the apical foramen and create a local response to the canal infection. The periapical inflammation does not cause symptoms during most of its existence. There appears to be a balance between the infection and defense forces. It is important to keep this in mind when examining a patient in pain. A radiolucent area does not equal pain. The patient’s history, including findings on clinical examination and radiographs, determines the need for therapy. All the classic symptoms of inflammation are involved in an exacerbated periapical inflammation—pain, swelling, redness, and lack of function. The tooth is tender to percussion and periapical palpation. To make the tooth free of symptoms, the infection has to be removed, which involves cleaning the root canal with antiseptic irrigants. Occasionally, a periapical inflammation flares up before radiographic signs are visible. These teeth are extremely painful and tender to percussion, and neither the patient nor the clinician has any problem localizing such teeth. Usually, treatment of a periapical flare-up does not require the use of antibiotics. Root canal cleaning and, when appropriate, drainage of an abscess through the canal or through an incision take care of the infection. This rids the patient of pain. If the patient has fever and malaise or an abscess develops, the use of antibiotics is necessary.
Acute dental pain typically responds to local treatment (e.g., ice packs and reduced mechanical stimulation) or to systemic nonsteroidal anti-inflammatory drugs (NSAIDs). Opioid analgesics are also occasionally indicated, depending on the extent of objective pathology. Opioids should be used only short-term and in combination with NSAIDs. In many cases, treatment with antibiotic agents is appropriate and palliative until a definitive dental intervention is performed.
Disorders of the Periodontium (Periodontal Disease)
Chronic periodontal disease is an immune-mediated inflammatory process initiated by pathogenic oral microorganisms that results in either focal or generalized areas of destruction of the tooth-supporting structures and surrounding bone. Chronic periodontitis is not generally a chronically painful disorder. Typically, patients may notice gingival sensitivity and tenderness or gingival enlargement because of inflammation and bleeding with brushing or probing examination. There is loss of gingival attachment around the necks of and soft tissue pocketing around the roots of the tooth with loss of bone support, which may result in tooth sensitivity, tenderness, and mobility. In the presence of an acute infection in the periodontal tissues, tenderness to the touch, erythema, and bleeding may be evident. An acute periodontal abscess may cause swelling and purulence ( Table 31.1 ). When inflammation or infection (i.e., acute pericoronitis) occurs in the soft tissue or bone around an erupting or partially erupted tooth (particularly third molars, otherwise known as “wisdom teeth”), similar signs and symptoms may be seen, with pain being a primary symptom.
| Diagnosis | Pulpitis | Periodontal Pain | Cracked Tooth | Dentinal Pain |
|---|---|---|---|---|
| Diagnostic features | Spontaneous and/or evoked deep/diffuse pain in compromised dental pulp. Pain may be sharp, throbbing, or dull | Localized deep continuous pain in compromised periodontium (e.g., gingiva, periodontal ligament) exacerbated by biting or chewing | Spontaneous or evoked brief sharp pain in a tooth with a history of trauma or restorative work (e.g., crown, root canal) | Brief, sharp pain evoked by different kinds of stimuli to the dentin (e.g., hot or cold drinks) |
| Diagnostic evaluation | Look for deep caries and recent or extensive dental work. Pain provoked/exacerbated by percussion and thermal or electrical stimulation of the affected tooth. Dental radiographs helpful (periapical) | Tooth percussion over compromised periodontium provokes pain. Look for inflammation or abscess (e.g., periodontitis). Apical dental radiographs helpful (bitewings, periapical) | Presence of a tooth fracture may be detectable on radiographs. Percussion should elicit pain. Dental radiographs are helpful (periapical taken from different angles) | Exposed dentin or cementum because of recession of the periodontium. Possible erosion of dentinal structure. Cold stimulation reproduces the pain |
| Treatment | Medication: NSAIDs, nonopiate analgesics | Medication: NSAIDs, nonopiate analgesics, antibiotics, mouthwashes | Medication: NSAIDs, nonopiate analgesics | Medication: mouthwash (fluoride), desensitizing toothpaste |
| Dentistry: remove carious lesion, tooth restoration, endodontic treatment or tooth extraction | Dentistry: drainage and débridement of the periodontal pocket, scaling and root planing, periodontal surgery, endodontic treatment or tooth extraction | Dentistry: depends on the level of the tooth fracture-restoration; treatment or extraction of the tooth | Dentistry: fluoride or potassium salts, tooth restoration, endodontic treatment | |
| Patient education on diet, tooth brushing force and frequency, proper toothpaste |
The pain of periodontal disorders is also generally responsive to NSAIDs, opioid analgesic agents, or combination analgesic agents. An acute abscess may also have to be locally incised and drained. Areas of generalized periodontitis may be treated by tooth scaling and curettage of the gingival pocket and possibly by local or systemic antibiotic therapy.
Oral Mucous Membrane Disorders
Diseases of the oral mucosa are numerous and due to a variety of local and systemic causes. Typically, these diseases are accompanied by pain and oral mucosal lesions, including vesicles, bullae, erosions, erythema, or red and white patches ( Box 31.5 ). Pain may be a symptom of the primary disease process, secondary to an associated process (i.e., infection), or related to damaged oral mucosa (i.e., mouth movements, chewing foods, thermal, chemical). The pain is often treated with both systemic and local analgesic agents.
Infections
Herpetic stomatitis
Varicella zoster
Candidiasis
Acute necrotizing gingivostomatitis
Immune/Autoimmune
Allergic reactions (toothpaste, mouthwashes, topical medications)
Erosive lichen planus
Benign mucous membrane pemphigoid
Aphthous stomatitis and aphthous lesions
Erythema multiforme
Graft-versus-host disease
Traumatic and Iatrogenic Injuries
Factitial, accidental (burns: chemical, solar, thermal)
Self-destructive (rituals, obsessive behavior)
Iatrogenic (chemotherapy, radiation)
Neoplasia
Squamous cell carcinoma
Mucoepidermoid carcinoma
Adenocystic carcinoma
Brain tumors
Neurologic
Burning mouth syndrome, glossodynia
Neuralgias
Postviral neuralgias
Post-traumatic neuropathies
Dyskinesias and dystonias
Nutritional and Metabolic
Vitamin deficiencies (B 12 , folate)
Mineral deficiencies (iron)
Diabetic neuropathy
Malabsorption syndromes
Miscellaneous
Xerostomia secondary to intrinsic or extrinsic conditions
Referred pain from esophageal or oropharyngeal malignancy
Mucositis secondary to esophageal reflux
Angioedema
Disorders of the Maxilla and Mandible
Numerous disorders of the bony substrate of the jaws can be associated with pain. These disorders are generally classified as being of odontogenic or nonodontogenic origin, cystic, cystic- or tumor-like, or benign or malignant (either primary or metastatic disease). There are often additional findings on the history or physical examination that warrant further evaluation (i.e., swelling, mass, discoloration, numbness, weakness, bleeding, drainage, tooth loss or mobility). Pain can be treated symptomatically until a definitive diagnosis is established and definitive therapy is initiated ( Table 31.2 ).
| Diagnosis | TMJ Articular Disorders | Muscle Disorders | Myofascial Disorders |
|---|---|---|---|
| Diagnostic features | Pain localized in the pre-auricular area during jaw function. Usually presence of a painful click or crepitus during mouth opening. Limited opening (<35 mm), deviated or painful jaw movements | Tenderness of the masticatory muscles. Dull, aching pain exacerbated by jaw function or palpation | Diffuse dull or aching pain affecting multiple groups of muscles of the head and neck region, as well as other parts of the body |
| Diagnostic evaluation | Internal derangement of the TMJ with abnormal function of the disk-condyle complex and/or degeneration of the joint surface. Palpation is painful. Possible joint swelling in acute phases. MRI, CT, etc., of the joint may rule out tumors and advanced degenerative stages | Tenderness during palpation of the masticatory muscles and tendons. Possible limited range of jaw movement and during passive stretching examination. Can be associated with a parafunctional habit (bruxism—early morning pain) | Presence of trigger or tender points in one or more groups of muscles. Pain can radiate to distant areas with stimulation or not of the trigger points. Rule out the presence of lupus erythematosus |
| Treatment | Patient education and self-care | Patient education and self-care | Same as for muscle disorders |
| Medication: NSAIDs, nonopiate analgesics | Medication: topical and systemic NSAIDs, nonopiate analgesics, muscle relaxants, antidepressants (usually TCAs), anxiolytics, anticonvulsants, BTX, trigger point injections, vapocoolant spray | ||
| Physical therapy: exercise program | Physical therapy: TENS, massage, exercise program | ||
| Occlusal splints | Occlusal splints | ||
| Oral maxillofacial surgery: arthrocentesis, arthroscopic surgery, open surgery | Cognitive-behavioral: biofeedback, relaxation, coping skills |
Salivary Gland Disorders
Disorders of the three pairs of the major salivary glands (parotid, submandibular, and sublingual) and the many hundreds of minor salivary glands within the oral cavity may also produce pain as a primary or associated complaint. These disorders are often accompanied by other signs and symptoms (including swelling, drainage, cervical adenopathy, or generalized symptoms of systemic infection), depending on the etiology of the disorder. Disorders of the parotid gland can extend locally to produce otologic symptoms or cranial nerve (V, VII, or IX) involvement. Disorders of the submandibular gland may result in symptoms of impaired swallowing or impairment of cranial nerves V, IX, and XII ( Box 31.6 ).
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Inflammatory
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Noninflammatory
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Infectious
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Obstructive
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Immunologic (Sjögren’s syndrome)
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Tumors
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Others (red herrings)
Burning Mouth/Tongue Disorder (Oral Burning)
Burning mouth/tongue disorder (BMD) is an idiopathic pain condition of the oral mucous membranes. It can be focal (inside of the lips or tongue) or generalized and is typically described as a constant, bilateral painful burning sensation. BMD generally affects middle-aged or older women and has been attributed to numerous oral disorders (e.g., mucous membrane disease, Sjögren’s syndrome/dry mouth, fungal infections) and systemic diseases (e.g., vitamin deficiencies, diabetes mellitus, immune connective tissue disorders, vasculitides). More recent evidence suggests that BMD is more likely a neuropathic pain disorder of either peripheral or central origin. Some recent taste-testing data and functional brain imaging studies seem to support this hypothesis ( Table 31.3 ). Current treatments of BMD focus on this hypothesis and the use of both topical (oral mucosa) and systemic antineuropathic pain medications (see Chapter 24 , Chapter 38 ); however, there is little evidence that such treatments are effective for BMD.
| Diagnosis | Trigeminal Neuralgia | Deafferentation Pain | Acute and Post-Herpetic Neuralgia | Burning Mouth Syndrome |
|---|---|---|---|---|
| Diagnostic features | Brief severe lancinating pain evoked by mechanical stimulation of the trigger zone (pain free between attacks). Generally unilateral, affects the V2/V3 areas (rarely V1). Possible pain remission periods (for months/years) | Spontaneous or evoked pain with a prolonged aftersensation following tactile stimulation. Trigger zone caused by surgery (tooth extraction) or trauma. Positive and negative descriptors (e.g., burning, nagging, boring) | Pain associated with herpetic lesions, usually in the V1 dermatome. Spontaneous pain (burning and tingling), but may be manifested as dull and aching. Occasional lancinating evoked pain | Constant burning pain of the mucous membranes of the tongue, mouth, hard palate, soft palate, or lips. Usually affects women older than 50 years |
| Diagnostic evaluation | MRI for evidence of tumor or vasocompression of the trigeminal tract or root (cerebropontine angle). Rule out MS, especially in young adults | Etiologic factors such as trauma or surgery in the painful area. Order MRI if the area is intact to rule out peripheral or central lesions | Small cutaneous vesicles (AHN) or scarring (PHN), usually affecting V1. Loss of normal skin color. Corneal ulceration can occur. Sensory changes in affected area (e.g., hyperesthesia, dysesthesia) | Rule out salivary gland dysfunction (xerostomia) or tumor, Sjögren’s syndrome, candidiasis, geographic or fissured tongue, and chemical or mechanical irritation. Nutrition and menopause |
| Treatment | Medication: anticonvulsants (e.g., carbamazepine, gabapentin), antidepressants (e.g., amitriptyline, nortriptyline, desipramine), nonopiate analgesics, BTX. Combination of baclofen and anticonvulsants can produce good results | Medication: anticonvulsants (e.g., carbamazepine, gabapentin), antidepressants, nonopiate analgesics, topical agents (e.g., lidocaine 5% patches) | Medication: acyclovir (acute phase), anticonvulsants, antidepressants, nonopiate analgesics, topical agents (e.g., lidocaine 5% patches) | Medication: anticonvulsants, benzodiazepines, antidepressants, nonopiate analgesics, topical agents (e.g., lidocaine, mouthwashes) |
| Surgery: microvascular decompression of the trigeminal root, ablative surgery (e.g., rhizotomy, Gamma Knife) | Surgery: ablative surgery (e.g., rhizotomy, Gamma Knife) | Surgery: ablative surgery (e.g., rhizotomy, Gamma Knife) | Cognitive-behavioral: biofeedback, relaxation, coping skills |
Sinus Disorders
Patients frequently describe their facial pain problem as a “sinus headache.” However, sinus disorders do not cause chronic headaches, and the clinician should look for a more specific cause of the pain symptoms in such cases. Diseases of the nose and paranasal sinuses typically cause acute pain associated with multiple other symptoms that are generally related to the specific nasal or sinus disease (i.e., allergic, inflammatory, infectious) ( Table 31.4 ). Acute dentoalveolar pathology of the maxillary posterior teeth can often be accompanied by signs and symptoms consistent with sinus disease. In addition, acute dentoalveolar inflammation or infection (dental abscess) can cause secondary maxillary sinus inflammation or infection. These disorders are typically acute in nature but can become chronic. This condition is often confused with other facial pain and headache disorders.
| Diagnosis | Paranasal Sinus Pain | Periocular Pain | Periauricular Pain | Head and Neck Cancer Pain |
|---|---|---|---|---|
| Diagnostic features | Bilateral or unilateral throbbing, pressure, or pain in the frontal area exacerbated by leaning forward or palpitation over the sinus | Pain or tenderness with or without eye movements, deep orbital pain, referred pain | Diffuse aching or sudden pain with or without an aural discharge (e.g., otitis media) | Variety of symptoms. Pain may be due to tumor, nerve compression, secondary infection, secondary myofascial pain, deafferentation, radiotherapy, chemotherapy |
| Diagnostic evaluation | History of chronic allergies, frequent URIs, sinusitis, headaches of various types, sinus surgery Refer to ENT for endoscopic and/or CT study (e.g., sinus opacification) | Examine the eyelids, lacrimal function, conjunctiva, sclera. Ophthalmoscopy and ophthalmology referral. Rule out primary headache, temporal arteritis, orbital pseudotumor | The area is innervated by multiple cranial and cervical nerves, so complete functional and structural examination is necessary (e.g., inspect the tympanic membrane, TMJ, and myofascia). CT and MRI invaluable for mastoiditis and cholesteatoma | Complete evaluation by multidisciplinary team, CT, MRI, endoscopy, biopsy, and surveillance. Treatment coordination by oncologist |
| Treatment | ENT evaluation/treatment | Proper ophthalmologic evaluation and treatment | Proper ENT evaluation and treatment | Oncologist evaluation and treatment |
| Medication: sinusitis—topical decongestants, systemic antibiotics Chronic sinus pain—NSAIDs, nonopiate analgesics, topical agents (lidocaine spray), anticonvulsants, antidepressants, BTX | Medication: NSAIDs, nonopiate analgesics. systemic antibiotics, topical corticosteroids, BTX across the forehead and glabellar areas in selected cases | Medication: NSAIDs, nonopiate analgesics, systemic antibiotics, topical corticosteroids, BTX in selected cases | Medication: anticonvulsants, antidepressants, opiate or nonopiate analgesics, topical agents, muscles relaxants | |
| Surgery | Surgery | Surgery | Surgery: ablative surgery |
Disorders of the Eye and Ear
Because numerous disorders can cause pain in and around the eye and ear, patients need to be evaluated for any primary ophthalmologic or otologic disease. Very often pain in and around these structures is also associated with a variety of other craniofacial and headache syndromes ( Boxes 31.7 to 31.9 ).
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Cluster headache and cluster-tic syndrome
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Paroxysmal hemicrania
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SUNCT syndrome
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Trigeminal neuralgia
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Sphenopalatine neuralgia (Sluder’s neuralgia)
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Ice pick headache
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Ice cream headache
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Hypnic headache
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Eye pain, headache, and lung cancer
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Nonorganic pain and headache (psychosomatic and psychiatric disorders)
SUNCT, s hort-lasting, u nilateral, n euralgiform headache attacks, c onjunctival injection, t earing.
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New visual acuity defect, color vision defect, or visual field loss
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Relative afferent pupillary defect
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Extraocular muscle abnormality, ocular misalignment, or diplopia
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Proptosis
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Lid retraction or ptosis
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Conjunctival chemosis, injection, or redness
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Corneal opacity
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Hyphema or hypopyon
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Iris irregularity
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Nonreactive pupil
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Fundus abnormality
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Recent ocular surgery (<3 months)
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Recent ocular trauma
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Multiple sclerosis plaques
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Tumors of the cerebellopontine angle
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Schwannomas
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Chiari malformations
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Midbrain lesions
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Pontine hemorrhage
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Vascular malformations
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Skull base tumors
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Small cell carcinomas
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Salivary gland tumors
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Oral cancers
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Carotid/vertebral disease
Tumors
Numerous intracranial and extracranial tumors can cause oral cavity, oropharyngeal, facial, and head pain as a primary symptom. Cancers of the upper aerodigestive tract, jaws, base of the skull, and neck may all be accompanied by pain along with other associated signs and symptoms. In addition, numerous intracranial tumors and lesions (i.e., vascular malformations) can be manifested as facial pain and headache. These are primarily tumors of the cerebellopontine angle; however, various primary brain neoplasms and metastatic disease have been associated with facial pain and headache. Headache and facial pain of unknown origin should warrant careful evaluation for an underlying occult tumor (see Boxes 31.7 and 31.8 ).
Patients with facial pain or headache should undergo a comprehensive medical history and careful physical examination with particular attention paid to the cranial neurologic examination. Consideration should be given to obtaining appropriate imaging studies, including computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance angiography.
Temporomandibular Disorders
Temporomandibular disorders (TMDs) are defined as a subgroup of craniofacial pain problems that involve the temporomandibular joint (TMJ), masticatory muscles, and associated head and neck musculoskeletal structures. Patients with TMDs most frequently have pain, limited or asymmetrical mandibular motion, and TMJ sounds. The pain or discomfort is often localized to the jaw, TMJ, and muscles of mastication. Common associated symptoms include ear pain and stuffiness, tinnitus, dizziness, neck pain, and headache. In some cases the onset is acute and the symptoms are mild and self-limited. In other patients, a chronic TMD with persistent pain develops in association with physical, behavioral, psychological, and psychosocial symptoms similar to those of patients with chronic pain syndromes in other areas of the body (e.g., arthritis, low back pain, chronic headache, fibromyalgia, chronic regional pain syndrome), all requiring a coordinated interdisciplinary diagnostic and treatment approach.
At least three distinct and separate dysfunctions that can create or affect the symptoms described by patients with a TMD are recognized :
- 1.
Muscle disorders (myofascial pain disorder [MPD]). MPD is related to muscle dysfunction, which often leads to muscle spasms, pain, and dysfunction. This type of dysfunction can occur in any skeletal muscle. The triggering area lies in the fascial coverings and attachment zones of the muscles, hence the term myofascial.
- 2.
Temporomandibular joint articular disorders (TMJDs). TMJDs are related to specific problems in the TMJs. These problems may range from joint sounds to locking, pain, and degenerative changes in the joints themselves. Invariably, muscle dysfunction is a secondary effect of true TMJDs.
- 3.
Cervical spinal dysfunction (CSD). This syndrome is related to the spinal column, the vertebrae, the ligaments, and muscles related to them. The majority of symptoms not directly related to the jaw muscles are triggered or affected by CSD syndrome.
Common associated signs and symptoms of TMDs that need to be evaluated are headache, facial pain, eye pain, ear symptoms, TMJ symptoms, neck pain, and arm and back symptoms.
Headache
Symptoms of bilateral head and facial pain involve multiple postural muscles or the muscles of mastication. The pain is dull and aching in quality with a chronic or persistent temporal pattern. It is typically moderate in intensity, and patients often exhibit daily symptoms that can wax and wane in severity. Exacerbations of pain are often provoked by functional use of the affected muscles. Morning headaches may be related to nocturnal bruxism, sleep disorders, or both. Increasing pain during the day may be related to muscle use or maintenance of head posture.
Facial Pain
Pain in the sides of the mandible and pain described by the patient as “sinus” pain in the zygomatic or orbital area may also have a musculoskeletal origin. Daytime clenching and acute or chronic stress, combined with a reduction in dental vertical dimension (height) related to loss of posterior teeth, can create muscle trigger points or muscle fatigue. This is particularly noticed by the patient after meals and reported as “a heavy and tired feeling” in the jaw muscles. Facial pain related to sinus and other pathologic conditions is discussed later in the chapter.
Eye Pain
TMDs frequently include pain symptoms that involve the eye and periorbital region. The pain is typically referred from other muscular sites, including the suboccipital region. Orbital pain symptoms are often described as unilateral, constant, and “boring.” This is frequently seen in patients with a history of trauma or chronic upper cervical vertebral subluxation or nerve root impingement related to the occiput and atlantoaxial region. In addition, entrapment of the greater occipital nerve at the occiput level can also produce this type of pain, which is often diagnosed as occipital neuralgia. It may frequently be amenable to physical medicine along with changes in head posture and mandibular position.
Ear Symptoms
Pain, stuffiness, and tinnitus may have a musculoskeletal etiology. Mandibular posture related to the maxilla affects the masticatory elevator muscles. The medial pterygoids are intimately related in the left-to-right balance of the mandible on tooth closure. The tensor tympani and tensor palati are actually one muscle with a raphe that wraps around the hamular notch of the maxilla. Improper growth of the maxilla during development may affect eustachian tube function and contribute to middle ear infections in children and stuffiness and changes in ear pressure in adults.
Tinnitus and other types of sounds may also have a musculoskeletal etiology. Specifically, cervical factors and mandibular postural factors have been seen in subjects with tinnitus. A combination of physical medicine and dental mouth guard therapy has been effective in some patients with a history of trauma or childhood growth affecting proper expansion of the maxilla. Ear pain that is sharp and jabbing on movement of the mandible is frequently seen in patients with internal derangement of the TMJ. This type of pain is generally unilateral and ipsilateral to the joint in question. Ear pain and symptoms such as stuffiness in the absence of positive otologic findings are among the most common reasons for evaluation of dental- and maxillomandibular-related imbalance. Treatment can often alleviate the symptoms completely or reduce their impact on the patient in conjunction with standard medical intervention.
Temporomandibular Joint Symptoms
Pain and sounds are very common with TMDs. The pain is typically unilateral and may be related to trauma or bruxism in the presence of missing posterior teeth; it can result in injury or anterior disk displacement without reduction and subsequent “locking” of the TMJ. Treatment often includes a combination of dental, medical, physical medicine, and mouth guard therapy plus stress management through biofeedback relaxation.
Neck Pain
Neck stiffness and pain are commonly part of the umbrella of TMDs. Trauma, habitual posturing, and musculoskeletal tension will chronically affect the cervical area and create pain, stiffness, and trigger points in the muscles of the head and neck. It is well documented that the trigeminal and cervical nerve systems are interactive in the maintenance of head, neck, and jaw posture. Examination of dental factors in patients with chronic neck pain is important because studies examining the relationship between maxillomandibular position and the cervical spine have shown that loss of vertical dimension of the teeth and a deep bite can adversely affect cervical muscle function and lead to chronic stiffness, pain, and a reduction in range of motion.
Arm and Back Symptoms
Patients with TMJDs will often also have other musculoskeletal findings, including shoulder pain and pain radiating down the arm that may or may not be accompanied by tingling or numbness. Physical examination may reveal positive signs of thoracic outlet syndrome, costoclavicular syndrome, vertebral subluxation or nerve impingement of the brachial plexus of nerves, and even previously undiagnosed rotator cuff injuries. Treatment requires a thoughtful multimodal approach to the various areas affected.
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