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Orofacial Pain – It’s All Connected

Have you ever had a patient with a toothache or orofacial pain? Of course you have—probably every single day. As a dentist, you treat all kinds of dental aches and pains on a regular basis. But sometimes patients suffer from more than just tooth-related aches and pains.

I have attended many continuing education courses that completely separate odontogenic pain from other forms of orofacial pain, which may involve the temporomandibular joint, muscles, and head and neck neuralgias. However, recent research and clinical experience have shown us that this is a mistake, as odontogenic pain often can refer to other parts of the head and neck, and vice versa.

The impact of head and neck pain

Have you ever carefully looked at a person with odontogenic or myofascial pain and considered how and why this pain might affect their oral and maxillofacial esthetics, as well as their mood? According to a May 2012 Journal of Psychiatric Research article, “Facing Depression With Botulinum Toxin: A Randomized Controlled Trial,”clinically depressed patients receiving botulinum toxin (BOTOX®) also showed improvements in their depression symptoms.

What exactly causes this improvement in mood? As a dentist, you may have met many patients who have been dealing with myofascial pain for a few months, or maybe a few years. Are they happy? What do their faces look like? Often these patients are depressed because they’ve been dealing with pain for so long. And, unfortunately, as facial muscles react to pain, more wrinkles, folds, and radial lip lines are going to appear. This deterioration of facial esthetics may even add to patients’ depression.

The link between head/neck and odontogenic pain.

Many dental professionals may not be aware of the pathways that exist between the head and neck muscles and the jaws and teeth. Deep tissue structures, such as muscles, tendons, the temporomandibular joint, and the dental pulp, all can be a source of local pain or refer pain along trigger point pathways.

In the past, those of us trained to identify trigger points in the head and neck muscles commonly thought that these pathways only worked one way—that the muscle would refer pain to the temporomandibular joint, other muscles, or the teeth (which would mimic dental pain). Now, research has shown us that when it comes to odontogenic pain, trigger pain pathways can be bidirectional.

There is plenty of evidence that these trigger point pathways are two-way streets. Authors of the article “Identifying Acute Pulpalgia as a Factor in TMD Pain,” published in the Journal of the AmericanDental Association (JADA) in June 1996, identify tooth pain as causing or contributing to myofascial pain and temporomandibular disorders. And according to the authors of “Pain After Routine Endodontic Therapy May Not Have Originated From the Treated Tooth,” a December 2011 systematic review published in JADA, approximately 680,000 teeth that may not have been the source of a patient’s pain receive endodontic therapy every year.

When I discussed these statistics with an endodontic colleague of mine who has been in practice for 40 years, he said he was surprised the number wasn’t higher, as he has performed endodontic therapy on many teeth that continued to be a site of pain for patients despite multiple treatments. Many patients receive endodontic therapy for tooth pain when in fact the problem is stemming from another origin in the face altogether. This should concern every dentist who does not currently know how to provide frontline treatment for temporomandibular joint (TMJ) disorder and myofascial pain.

Beyond the teeth

So how do dentists ensure they are actually getting to the root of the problem and treating the main cause and source of pain? A comprehensive and efficient head and neck examination should be a routine part of every dental visit, especially when the patient has any kind of orofacial pain, including odontogenic pain. Dental professionals are not just “teeth mechanics“; they should be the primary health care providers who treat odontogenic and orofacial pain.

Too many dental offices operate like a dry cleaner—when patients come in, they might as well just take the teeth out of their mouths, drop them off, get them cleaned or fixed, and then pick them up later. Sounds ridiculous, right? Teeth are connected to the jaws, which we must remember 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 provider who can treat all of the pieces together.

All pain in the head and neck region, whether in the mouth or out of the mouth, should be considered orofacial pain. It is all connected—even to patients’ facial esthetics and quality of life. You can’t separate odontogenic pain, orofacial pain, and dental and facial esthetics; that would be like saying you only treat the teeth but don’t treat the occlusion. When you treat one, you must treat them all.

As a general dentist, you need to know how all of the facial and masticatory muscles work, because if there is pain in these muscles, there very likely will be pain in the teeth, and vice versa. By learning some basic skills to facilitate treatment of the head and neck muscles, you will become your patients’ true orofacial pain “specialist.”

When you treat a toothache or orofacial pain and solve a patient’s problem, he or she will look better and feel better immediately—what an awesome responsibility and opportunity to really help your patients. Stop ignoring these patients and learn some frontline TMJ and myofascial pain techniques to use in addition to your regular treatment of the teeth; you will be amazed by the improvement in your treatment outcomes and the speed with which your practice will grow.

Louis Malcmacher, DDS, MAGD, is a practicing general dentist and an internationally known lecturer and author known for his comprehensive and entertaining style. Dr. Malcmacher is the president of the American Academy of Facial Esthetics. Contact him at

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