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By Louis Malcmacher, DDS, MAGD, DAAFE Tuesday, July 08, 2014 10:15 AM

Did you ever have a patient with a toothache or orofacial pain? Of course you have, every single day. One of the primary areas of dentistry is dealing with all kinds of toothaches and orofacial pain on a daily basis. I have been to many courses in my career that completely separate odontogenic pain from other forms of orofacial pain which may involve the TMJ, muscles, and head and neck neuralgias.  Now we know that this a very common mistake as many times odontogenic pain can refer to other parts of the head and neck and vice versa.

Have you ever carefully looked at a person with odontogenic or myofascial pain? How and why would it affect their oral and maxillofacial esthetics? And would it also affect their mood?  There was a recent study that showed that when a patient receives botulinum toxin (Botox®) for esthetic reasons or chronic migraine, patients that had clinical depression got better.  Since that study, the American Academy of Facial Esthetics (AAFE) has received a number of inquiries from psychiatrists and psychiatric nurses wanting to learn how to use botulinum toxins to treat depression!

How many times have you had a patient that has had myofascial pain and been in pain for a few months or years? Are the patients happy?  What do their faces look like? Usually, they are somewhat depressed from being in pain for so long, you would be too.  Their faces are usually sad, scowling, scrunched up from acute pain attacks. The more the facial muscles react to pain, the more wrinkles, folds, and radial lip lines they are going to have. The patient’s decreasing facial esthetics is also going to add to their already sour depression or mood.

In addition, when it comes to odontogenic pain, we now know that trigger pain pathways are bidirectional. What many dental professionals are not aware of and have not been taught is the existence of trigger point pathways that exist 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 have been trained could identify trigger points in the head and neck muscles, would commonly think that these pathways only worked one way – and that is, the muscle will refer pain to the TMJ, other muscles or to the teeth which would mimic dental pain.

A 2011 JADA article estimates that there are approximately 680,000 teeth that receive endodontic therapy every year when the tooth may not have been the source of the pain. Likewise, a 1996 JADA article identifies tooth pain as causing or contributing to myofascial pain and TMD.  There is now plenty of evidence that shows that these trigger point pathways is really a two way street.  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 are any kind of orofacial pain.  I recently spoke at a dental meeting where my host was an endodontist for 40 years – as I discussed this with him, he was surprised that the number of 680,000 wasn’t higher!  He saw so many of the teeth he performed endodontic therapy on continue with pain even after multiple treatments. The number of 680,000 teeth receiving endodontic therapy when in fact the problem was coming elsewhere should alarm every single dentist who does not know how to provide frontline TMJ and myofascial pain therapy.

This once again emphasizes the fact that dental professionals are not just “teeth mechanics”.  Too many dental offices operate like the dry cleaners – patients come into many dental practices and 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.  Of course, they can’t do that 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 healthcare professional that can connect and treat all of these pieces together.

Dentists are the primary healthcare providers that will treat odontogenic and orofacial pain – pain in the head and neck region whether it is in the mouth or out of the mouth is all considered orofacial pain and as you now see it is all connected and it is even connected to their facial esthetics and their psychiatric status!  It is almost like saying that your dentist only treats teeth but you don’t treat the occlusion.  You can’t separate the odontogenic pain, orofacial pain, and dental and facial esthetics – when you treat one, you treat them all!  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.

It is time for every dentist to learn some basic skills to be able to include treating the head and neck muscles with all of the dental treatment that you now provide and then you will be the true orofacial pain “specialist” to your patients.  When you treat a toothache and orofacial pain and solve the patient’s problem, they will look better and they will feel better about themselves immediately. What an awesome responsibility and opportunity to really help patients.

Stop ignoring these patients, come to the AAFE course on Frontline TMJ, Headaches and Orofacial Pain Live Patient training and Botox® Live Patient Training where you can learn some frontline TMJ and myofascial pain techniques to use in addition to your skills in treating teeth, and you will be amazed at how much better your treatment outcomes will be and how fast your practice will grow.

Join the AAFE members who have added these services to their practice along with dermal fillers, bruxism therapy and dental sleep medicine, and have added an average of $26,500 to their monthly production.  Give patients what they want and that is to sleep better, look better, and feel better.

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