TMJ & Facial Pain

TMJ and facial pain is another one of those challenging conditions where the pathology is not easy to define and several specialities can be involved in co-ordinating patient management.  These may include dentists, pain management specialists, ENT, neurology, physiotherapy and the whole myriad of allied health professionals.  It is often difficult to quantify whether the facial symptoms are primary or secondary in nature even when a specific mechanical history is reported.  One of the reasons for this is that often a traumatic mechanism involving the head and neck can simultaneously irritate multiple structures and therefore doesn’t narrow down the examination process.  Similarly mechanisms such as whiplash which do not directly involve the jaw as a point of impact also appear to be capable of inducing secondary irritation either by way of reflex changes or as a consequence of the inertia from violent head and upper thorax motion.

Specific symptom reports such as clicking, locking, opening restriction, pain on bite, fatigue on talking and slowness of speech are all frequent symptom reports from patients with primary TMJ problems.  There may well be some localised tenderness along the joint line also.

When patients describe overt locking and clicking there are a number of possibilities to be considered.

1)      Intra-articular disc pathology – This is usually a clinical diagnosis which requires arthroscopic confirmation and management.

2)      Intra-articular impingement secondary to capsular restriction – Patients in this grouping display restricted motion of the TMJ sometimes in a global pattern and sometimes direction specific.  The primary treatment strategy in this patient group is to improve joint mobility by re-evaluating the intra-articular pain pattern post-intervention.

3)      TMJ instability – This is a most challenging group where the structural constraints have become either torn or chronically elongated thus compromising stability in the region.  Patients in this category are often the poor responders to treatment or those who require on going maintenance as part of their management strategy.

Secondary TMJ Pain – Myofascial pain radiating to the face, head and jaw is extremely common.  In the presence of a post whiplash history there will often be co-existing cervicogenic signs, headaches and even neuropathic symptoms in the head and face as part of the general symptom pattern.  In clear-cut cervicogenic myofascial referral the symptoms can be reproduced by palpation of trigger points in;

Trapizus

Sternocleidomastoid

Scalene

Scapular musculature.

Specific evaluation of the face and jaw with palpatory techniques does usually not yield sufficient information but diagnostic probing using dry needling is certainly worthwhile. Combinations of manual therapy specifically to the joint condyles together with hold- relax procedures in the direction of motion restriction are all part of the tools normally used to manage this type of condition.  The therapist should be aware that intra-oral techniques are usually required so appropriate gloving and preparatory procedures are necessary.

A common clinical challenge we face is patients who have regular sleep disturbance following a traumatic neck injury.  This cycle of sleep disturbance if sustained for any period induces fatigue with subsequent diffuse increases in muscle tension.  When this cycle involves into a pattern of habitual teeth grinding, known as ‘Bruxism’ this seriously compounds the clinical management.  It is particularly important to identify in persistent head and facial pain and the clinician is looking for a pattern of temporary response to localised modalities but recurrence of symptoms on an on going basis.  Typically these patients don’t show gross range of motion restrictions but do exhibit diffuse sensitivity on palpatory testing.

The strategies used to control Bruxism may involve relaxation, dental splinting, and evaluation of bite mechanics as well as looking at other muscular skeletal and postural drivers to potential persistence of muscle hyperactivity.  Undoubtedly an interesting and challenging caseload and one that often involves collarabation of health care professionals – true multi-disciplinary pain management.

Enjoy the clinical challenge.

David.