Dental Economics June 2013 by Dr. Louis Malcmacher
One of the primary areas of dentistry is dealing with orofacial pain. Every kind of tooth pain is, in effect, orofacial pain. I’ve attended many courses in my career that keep odontogenic pain completely separate from other forms of orofacial pain that may involve the TMJ muscles and head and neck neuralgias. This is a very common mistake as many times odontogenic pain can refer to other parts of the head and neck and vice versa. What many dental professionals are not aware of and have not been taught about is the existence of trigger point pathways between the head and neck muscles and the jaws and teeth. Deep tissue structures such as muscle, tendons, TMJ, and the dental pulp can all have pain either locally right at their source, or refer pain along trigger point pathways. In the past, those of us who were trained to identify trigger points in the head and neck muscles commonly thought that these pathways only worked one way. There is now plenty of evidence that shows that these trigger point pathways are a two way street. A 2011 JADA article estimates that about 680,000 teeth receive endodontic therapy every year when the tooth may not be the source of the pain. Likewise, a 1996 JADA article identifies tooth pain as causing or contributing to myofascial pain and TMD. Putting all of this together, a comprehensive and efficient head and neck examination should be a routine part of every dental examination, especially when the patient’s symptoms include orofacial pain. What is a trigger point? A trigger point is a hypersensitive area typically in a muscle, and it can be found upon examination by applying four to eight pounds of pressure in that muscle for six to 10 seconds. The trigger point pathway is from where the trigger point is to the place where the pain is actually felt. If we press that muscle and the pain is felt in a remote site, then we define the patient’s condition as myofascial pain. The trigger point pathway is a two way street – there are many trigger points found in the temporalis muscle that, when activated, the pain is felt anywhere from the anterior to the posterior upper teeth. Conversely, if there is some pathology with one of the maxillary teeth, this pathway could work from the odontogenic origin and the patient could exhibit pain in the temporalis muscle or around the temporomandibular joints, mimicking, causing, or exacerbating TMD syndrome. Now that you’ve been exposed to the concept of trigger point pathways, this emphasizes the fact that dental professionals are not just “teeth mechanics.” Too many dental offices operate like a dry cleaners – patients might as well just take out their teeth, drop them off, get them cleaned or fixed, and pick them up later. Of course they can’t do this because, to make a point more strongly, the teeth are connected to the jaws that are connected to the muscles and all of the structures of the head and neck. They are all connected, and you, the dental professional, are the only health-care professional that can connect and treat all of these pieces. All it takes is learning some basic skills in order to include the head and neck muscles with your current dental treatment, and then you will become the true orofacial pain “specialist” to your patients. Stop ignoring these patients, learn how to do a thorough head and neck examination to identify trigger points, learn some frontline TMJ and myofascial pain techniques, and you will be amazed at how much better your treatment outcomes will be and how fast your practice will grow. LOUIS MALCMACHER, DDS, MAGD, is a practicing general dentist, lecturer, author, and dental consultant. An evaluator emeritus for CLINICIANS REPORT, he is the president of the American Academy of Facial Esthetics. Contact him at (800) 952-0521 or drlouis@ FacialEsthetics.org. Sign up for a free monthly newsletter at www.commonsensedentistry.com.