FOCUS ON: Myofascial Pain
Louis Malcmacher, DDS, discusses the link between facial pain and facial esthetics and treatment options.
Q: Where does most facial pain come from and what does it have to do with facial esthetics?
A: Well, like anything else, we always start with the evidence-based studies. Those dealing with myofascial pain show that 85% of temporomandibular joint (TMJ) dysfunction and orofacial pain come from muscles of the head and neck. It’s finally time to understand the muscle trigger point mechanisms that have been studied and identified for more than 50 years. In short, a trigger point is a sensitive point in a muscle that will refer pain to a remote site. Trigger point pathways are well established and widely known to healthcare professionals, especially those in orthopedic medicine, physical medicine, and physical therapists; however, these have basically been ignored in dentistry. A good example of a trigger point is an area in the masseter muscle that can refer pain to the lower teeth. You can have a trigger point in your shoulder (which practically every dentist I know suffers from) that can refer pain to the corner of the jaw and mimic a toothache. The interesting thing about these trigger point pathways is that they are bidirectional. If you have a problem with a tooth or occlusal dysfunction that is causing pain in teeth, these teeth can refer back to one of the head and neck muscles. That’s why having a stable occlusion certainly plays a role in myofascial pain.
Once and for all, we have to fully realize that muscles can have their own pathology completely separate from occlusion. In my lectures, I am challenged all the time by those who say that we have to find the source of what is causing the muscle spasm, and it has to be coming from the occlusion. That concept is not supported by any evidence- based studies and it is high time that we realize that muscles can and do have their own pathology and need to be treated as part of a comprehensive treatment plan.
Q: How is facial pain tied to facial esthetics?
A: The same muscles of mastication and facial expression that cause the majority of myofascial pain and TMJ dysfunction are also the muscles that create facial esthetics. Let me give you an example: if the frontalis (forehead muscle) is causing wrinkles in the patient’s forehead and at the same time is the source of facial pain, I need to treat the frontalis. When I do, the pain will go away, and at the same time so will the wrinkles in the skin because both are caused by the intensity of contraction of this frontalis muscle. If a patient has strong hypertrophic masseter muscles, and he or she is bruxing all day long, teeth will be broken. In addition, the patient will have a very square looking face caused by the shape of the muscle.
Using chemotherapeutics to reduce the intensity of contraction of that muscle will also cause the muscle to return to a normal shape and create a much nicer facial esthetic appearance at the exact same time.
Q: What is chemotherapeutics?
A: Chemotherapeutics simply means using a pharmaceutical agent to treat the trigger points in the muscles. A trigger point injection by itself is treatment of the muscle and every dentist reading this article should be trained in how to give a proper trigger point injection. There are 2 parts to a trigger point injection; one is the actual physical procedure of the injection and the other is the pharmaceutical agent that is injected into the muscle. The American Academy of Facial Esthetics (AAFE) has pioneered the use of botulinum toxin (Botox®) for trigger point injections. Botox® used in the muscles of facial expression and muscles of mastication, in its proper dosages, will eliminate or reduce the intensity of contraction in these muscles and at the same time will deliver an esthetic effect in eliminating wrinkles caused by the same muscles and eliminate the unsightly esthetics caused by the muscular action on the skin. This is why it is incumbent that every dental practitioner who treats myofascial pain patients be properly trained in facial esthetics.
Q:Botox® for facial pain? How long has that been around?
A: The use of Botox® for myofascial pain has been around for more than 20 years. In 2011, the FDA approved the use of Botox® for chronic migraine. The FDA protocol calls for the use of Botox® in all the same muscles that are commonly treated for esthetic purposes in the maxillofacial areas. The AAFE has been teaching a number of different protocols for the treatment of myofascial pain and facial esthetics for the last several years to thousands of dentists in North America. The AAFE’s more than 7,000 dental members have successfully integrated these concepts and treatments into their office to where know this has become standard practice that is creating outstanding therapeutic and esthetic outcomes for patients who have been suffering for a very long time and could never get full relief from traditional treatments that dentists have used in the past.
Q: Are facial esthetics and facial pain treatment really within the scope of general dentistry?
A: This question has definitively been answered. The ADA and AAFE partnered together on a live patient Botox® treatment training course at the ADA Annual Session in New Orleans this past October, where I also presented an education in the round live patient demonstration to hundreds of dental professionals that was broadcast on ADA365. To put it succinctly, the answer is yes, facial pain and esthetic treatment are now well integrated into dentistry and dental professionals should receive comprehensive training to achieve better patient outcomes than ever before. Get trained today!