Dr. Shapira's Chicago Headache Blog

The article "emporomandibular dysfunction: an often overlooked cause of chronic headaches" published in Ann Allergy Asthma Immunol. 2007 Oct;99(4):314-8 recommends evaluating patients with chronic daily headaches for TMJ disorders. This interesting article looks at 25 years of Pub Med searches of the keywords " temporomandibular dysfunction, temporomandibular disorder, temporomandibular joint, and chronic headache". The article concludes "The disorder should be suspected in individuals with a long-standing history of chronic daily headaches and facial pain without objective evidence of sinus, neurologic, or intracranial abnormalities."

The article is directed to ENT and allergy physicians and notes "Allergists and immunologists are frequently called on to evaluate patients with chronic headaches and facial pain. TMD is known to cause recurrent facial discomfort and headaches. Many individuals with the disorder present with headache or facial discomfort as their only chief complaint. They mistakenly think it is a "sinus" headache. Nearly 10 million Americans are affected by the disorder, and early studies estimate that TMD pain is the cause of chronic headaches in 14% to 26% of individuals with recurrent headaches"

NEUROMUSCULAR DENTISTRY CAN DIAGNOSE AND TREAT CHRONIC DAILY HEADACHES BY UTILIZING A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC. A DIAGNOSTIC ORTHOTIC , WHEN SUCCESSFUL IN ELIMINATING PAIN NOT ONLY IS THE FIRST STEP OF TREATING OR CURING THE DISORDER BUT ALSO GUIDES THE PRACTITIONER IN THE BEST MEANS OF TREATMENT.

ACCORDING TO THIS ARTICLE "As such, many patients with the disorder are routinely mislabeled as experiencing chronic sinusitis and are unnecessarily subjected to multiple courses of broad-spectrum antibiotics and other unnecessary therapy"

This is not uncommon. TMJ or TMD is frequently called "THE GREAT IMPOSTER" because patients are frequently given multiple courses of antibiotics to treat non-existent infections, given migraine medications for headaches that are myofascial in orgin or subjected to multiple CAT scans and MRI's that are essentially normal. Please see the Sleep and Health Article "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" to leatn more about how neuromuscular dentistry can help eliminate, prevent or alleviate migraines, tension-type headaches, chronic daily headaches, facial pain or sinus pain and/or pressure. These are all frequently symptoms of TMJ disorders.

Additional information on Neuromuscular Dentistry can be found in "Neuromuscular Dentistry" an article originally published by the American Equilibration Society that has been republished in Sleep and Health Journal @ http://www.sleepandhealth.com/neuromuscular-dentistry

'
PubMed abstract below
Ann Allergy Asthma Immunol. 2007 Oct;99(4):314-8.
Temporomandibular dysfunction: an often overlooked cause of chronic headaches.
Lupoli TA, Lockey RF.

Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, University of South Florida College of Medicine, James A. Haley Veteran's Hospital, Tampa, Florida 33612, USA. tlupoli@hsc.usf.edu
OBJECTIVE: To review and discuss the role of temporomandibular dysfunction (TMD) as a cause of chronic headaches and facial pain. DATA SOURCES AND STUDY SELECTION: A literature review was performed using the PubMed database for English-language articles published between January 1, 1981, and August 31, 2006, using the following keywords: temporomandibular dysfunction, temporomandibular disorder, temporomandibular joint, and chronic headache. Additional information was obtained from a review of current medical texts. RESULTS:. CONCLUSIONS: TMD is a likely underdiagnosed cause of chronic headache and facial discomfort. As such, many patients with the disorder are routinely mislabeled as experiencing chronic sinusitis and are unnecessarily subjected to multiple courses of broad-spectrum antibiotics and other unnecessary therapy. TMD can be readily diagnosed by a careful history and physical examination. Patients typically respond well to conservative therapy, which includes behavioral modification and nonsteroidal anti-inflammatory drugs. The disorder should be suspected in individuals with a long-standing history of chronic daily headaches and facial pain without objective evidence of sinus, neurologic, or intracranial abnormalities.

PMID: 17941277 [PubMed - indexed for MEDLINE]

Labels: CGRP neuromuscular dentistry, facial pain TMJ, sinus headache, sinus infection, sinus pressure, TMD, TMJ sinus

A new study Chronic Headache and Comorbibities: A Two-Phase, Population-Based, Cross-Sectional Study in Headache. 2010 Feb 12 is very revealing. It was evaluating chronic daily headaches, pschiatric disorders and TMD. In the study "Individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH (chronic daily headache) were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2).

Of the 1631 subjects 57 (3.6%) had CDH. Chronic migraine comprised represented 36.8% and Chronic tension-type headache represented 17.5%. Medication overuse headache was also common representing 22.8% and probable medication overuse headache representing another 17.5% were also common combined totaling 40.3% of Chronic daily headaches

There were TMD comorbidities observed in 58.1% of the patients. This is no surprise as the trigeminal nerve is almost universally involved in chronic headaches. If a thorough neuromuscular detistry evaluation was done it is likely the percentage of patients with TMD signs or symptoms would be much higher. There were also psychiatric disorders were observed in a large percentage of these patients but living with chronic pain can frequently manifest itself in secondary psychiatric problems.

I frequently find that patients who are in chronic pain, not sleeping well and overutilizing medications change ramatically after they begin using a diagnostic orthotic. I sometimes feel I don't meet the patients until their second or third visit after significant pain reduction.

It is normal to be depressed when you are in constant non-remiting pain. I have frequently said that patients in constant pain who do not become depressed are "certifiable".

When considering comorbidities it is important to understand that TMD is a causitive comorbidity that helps create the chronic headaches while the psychiatric comorbidity may be a result of the pain or not related to the pain problem.

If one was to consider medication overuse a comorbidity then the data would skew considerably. Is the medication overuse headache a symptom of the underlying TMD or psychiatric disorder. Patients with TMD are prone to seeing a wide variety of health practitioners before being diagnosed with tmd (TMJ) disorders. TMD is know as "The Great Imposter" for that reason. Please see the Sleep and Health article "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor

TMD IS SUCH A MAJOR COMORBIDITY IN HEADACHES THAT EVERY PATIENT WITH CHRONIC HEADACHES OR MIGRAINES SHOULD BE EVALUATED FOR TMD PRIOR TO INITIATING MEDICATION. A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC MAY ELIMINATE THE PAIN PROBLEMS THEREBY AVOIDING FUTURE MEDICATION OVERUSE HEADACHES AND ASSOCIATED PSYCHIATRIC PROBLEMS FROM BOTH PAIN AND MEDICATION OVERUSE.





PUBMED ABSTRACT below
Headache. 2010 Feb 12. [Epub ahead of print]
Chronic Headache and Comorbibities: A Two-Phase, Population-Based, Cross-Sectional Study.
da Silva Jr A, Costa EC, Gomes JB, Leite FM, Gomez RS, Vasconcelos LP, Krymchantowski A, Moreira P, Teixeira AL.

From the UFMG - Headache Clinic, Belo Horizonte, Brazil (A. da Silva Jr, E.C. Costa, J.B. Gomes, and F.M. Leite); University Hospital, Federal University of Minas Gerais - Headache Clinic, Neurology Division, Belo Horizonte, Brazil (R.S. Gomez); Federal University of Minas Gerais (UFMG) - Internal Medicine, Belo Horizonte, Brazil (L.P. Vasconcelos and A.L. Teixeira); Universidade Federal Fluminense - Neurology, Rio de Janeiro, Brazil (A. Krymchantowski); Universidade Federal Fluminense - Headache Clinic, University Hospital, Rio de Janeiro, Brazil (P. Moreira); Federal University of Minas Gerais (UFMG) - Laboratory of Immunopharmacology, Belo Horizonte, Brazil (A.L. Teixeira).
Background.- Studies using resources of a public family health program to estimate the prevalence of chronic daily headaches (CDH) are lacking. Objectives.- To estimate the 1-year prevalence of CDH, as well as the presence of associated psychiatric and temporomandibular disorders (TMD) comorbidities, on the entire population of a city representative of the rural area of Brazil. Methods.- This was a cross-sectional, population-based, 2-phase study. In the first phase, health agents interviewed all individuals older than 10 years, in a rural area of Brazil. In the second stage, all individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2). Medication overuse headache was diagnosed, as per the ICHD-2, after detoxification trials. Psychiatric comorbidities and TMD were diagnosed based on the DSM-IV and on the Research Diagnostic Criteria for Temporomandibular Disorders criteria, respectively. Results.- A total of 1631 subjects participated in the direct interviews. Of them, 57 (3.6%) had CDH. Chronic migraine was the most common of the CDH (21, 36.8%). Chronic tension-type headache (10, 17.5%), medication overuse headache (13, 22.8%) and probable medication overuse headache (10, 17.5%) were also common. Psychiatric disorders were observed in 38 (67.3%) of the CDH subjects. TMD were seen in 33 (58.1)% of them. Conclusions.- The prevalence of CDH in the rural area of Brazil is similar to what has been reported in previous studies. A significant proportion of them have psychiatric comorbidities and/or TMD. In this sample, comorbidities were as frequent as reported in convenience samples from tertiary headache centers. (Headache 2010;**:**-**).

PMID: 20163479 [PubMed - as supplied by publisher

Labels: Chicago, chronic daily headacahe, chronic daily headaches, chronic daily migraine, comorbidities, facial pain TMJ, ILlinois, Kenosha, lake county, TMD

All patients with TMJ disorders especially if they get morning headaches or are tired during the day should be evaluated for sleep apnea. Sleep apnea (see www.ihatecpap.com) is a collapse of the airway during sleep.

Patients with clicking or popping TM joints will frequently have resolution of the TM Joint (temporomandibular joint) clicking if they wear a sleep apnea oral appliance.

The appliance stabilizes the condyle of the TMJ forward and if the disc is reduced allows time for the soft tissues to heal and stabilze the disc.

This stabilization will require the use of a daytime neuromuscular (splint) orthotic to maintain joint stability during the day.

Labels: CGRP neuromuscular dentistry, chronic daily headaches, facial pain TMJ, improving quality TMD, morning headache, temporomandibular joint, TMJ clicking, TMJ pain, TMJ popping

Patients missing one or more permanent molars are more prone to headaches and TMJ disorders. Missing just a single first molar has been shown to double the resk of headaches, sinus pain and /TMJ disorders. When the molars are missing there can be drastic increases in headaches and TMJ disorders. Patients with loss of vertical dimension are more prone to morning headaches, sleep apnea and migraines.

Dental Implants are frerquently used to replace missing teeth when treating headaches and migraines associated with TMJ diorders.

Labels: Dental Implant, dental implants, facial pain TMJ, implant dentistry, Migraines, missing teeth, neuromuscular dentistry, neuromuscular dentistry tmd

When chronic or acute ear pain occurs an evaluation by an otolaryngologist or ENT is a good way to begin treatment. The exception to this rule is when movements of the lower jaw cause the ear pain or the motion of the lower jaw is limited. This is a sign of a TMJ disorder. If it happens suddenly it may be the sign of an acute close-lock of the TM Joint and a dentist with experience in treating temporomandibular disorders is a must. Neuromuscular Dentistry is extremely effective in treating chronic haeadaches, migraines, Tension Headaches and TMD but when an acute close lock occurs time is of the essence to prevent permanent damage.

Many neuromuscular dentists know how to manage the chronic pain aspect of TMD but are less sure of handling an acute disk dislocation.

The wrong treatment is to not attempt to reduce the dislocation, taking anti-inflamatories or pain meds without attempting to reduce the dislocation. The longer the disk is out the more likely there will be permanent damage or internal derangement of the TMJ.

A trip to the emergency room is usually non-productive or may even create additional damage if they try to force the jaw open.

A simple method to reduce a close-lock it to stimulate a strong gag reflex which will sometimes reduce the dislocation. It is then necessary to stabilize the joint with an orthotic.

Labels: atypical migraine, ear pain, facial pain TMJ, migraine neuromuscular dentistry, neuromuscular dentistry, otalgia, temporomandibular joint, TM Joint, TMD Migraine

Chronic pain is frequently multifactorial in nature. Neuromuscular dentistry has been very successful in treating TMD, Migrines, Tension Type headaches and other disorders. Frequently it is not a total cure but 50-80% reduction in pain is usually attained within several visits. There are many disorders and symptoms associated with TMD including:
Ear Aches or Otalgia
Sinus Pain
TM Joint Clicking and Popping
Ear Stuffiness or Eustacian Tube Dysfunction
Dizziness
Vertigo
Temporal Pain
Occipital Headaches
Morning Headaches
Sleep Apnea
Snoring
Sore Throats
Neck pain or stiffness
Feelings of a foriegn object in the throat
Pain in or behind the eyes
Scalp pain or feeling like your hair hurts

Most of these symptoms are mediated by the Trigeminal nerve and the Trigeminovaqscular system. These Nerves also connect to facial nerves, occipital nerves, glossopharyngeal nerves and to the autonomic nervous system. What happens in these nerves cause biochemical changes in the brain. Recent stuies shown the neural plasticity can create permanent changes in the brain. If chronic pain is the stimulus it can lead to central sensitization.

Changes inthe brain can be reversed over time but the exact amount of recovery will vary with individual patients genotypes, how long the pain has been present , other comorbidities that the patient carries. Some patients experience immediate3 and almost miraculous pain relief while others have a slower longer version of recovery. I always tell my patients to work for 50 - 80% improvement in pain. That is then our new starting point and we again seek 50 - *0 % reduction in pain.

There is "no cure" for long term chronic pain because lives have been changed due to living with pain. A cure would require a do-over of the years you had pain. There are no do-overs therefore we look to improve your future quality of life to the maximum. Some patients still have to do exercises or watch diet or even continue different medications. Other patients have remarkably and incredible improvements as described by Dr Barry Cooper in Cranio where he talked about "overwhelming success". This is why we use a diagnostic orthotic as the first step of treatment. We try to avoid permanent changes until the patient feels substantially improved. This is not a judgement that any doctor can make for the patient. It is a subjective evaluation by the patient themselves. Only the patient knows how well or poorly they are doing. We may have objective data showing physical improvement but the final test is have we improved or dramatically improved the patients quality of life. If the answer is yes we can talk about long term stabilization. The diagnostic orthotic is the first phase of treatment for those patients.

If the patient has improvement, whether it is only 25-30% or if they are at 80-90% the decision that the diagnostic orthotic treatment is successful remains the patient's. If they do not feel sufficiently improved they should not feel pressured into continuing treatment or making permanent changes. You should treat the diagnostic orthotic like a CAT SCAN or MRI but instead of images we have improvement in the quality of life. If improvement is not sufficient then a diagnostic approach should continue.

While NEUROMUSCULAR DENTISTRY IS REMARKABLY EFFECTIVE AT TREATING MANY CONDITIONS THERE ARE OTHER CONDITIONS THAT ARE NOT RELATED TO THE TRIGEMINAL NERVOUS SYSTEM, MYOFASCIAL PAIN OR JAW JOINTS.

TMJ disorders are frequently called The Great Imposter ("SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" IS A MUST READ FOR ANY PATIENTS WITH MIGRAINES OR TMD http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor) but we must remember that other disorders can also masquerade or more frequently coexist with these problems. Many times a diagnostic orthotic relieves many of the symptoms but the remaining symptoms have a different cause. The expression that "you can't see the forest for the trees" applies. When the majority of symptoms are relieved you now find that you can identify a particular problem that was lost in a long and winding maze of symptoms. As NMD unravels the maze a specific problem can now be identified and treated.

Labels: chronic daily headaches, diagnostic orthotic, facial pain TMJ, Migraines, neuromuscular dentistry, neuromuscular dentistry tmd, neuromuscular orthotic, quality of life, TMJD

A recent article points to the use of CRCP (Calcitonin gene-related peptide) antagonists to treat migraines. Levels of CGRP rise during migraine and experimentally injecting IV CRCP can provoke migraine. Two CGRP antagonists are being tested inthe study from Acta Neurol Belg. 2009 Dec;109(4):252-61.

CGRP is produced by the trigeminovascular system. Many patients who undergo treatment with a diagnostic neuromuscular orthotic frequently see migraines decreased and/or eliminated. A future area of study would be does Neuromuscular Dentistry work by decreasing CGRP release from the trigeminal nerve. I consider most problems to be input/output errors of the trigeminal nervous system. Do noxious inputs from the teeth, jaw muscles, jaw joints, and periodontal ligament cause surges in CRGP in susceptible individuals causing migraine.


PubMed abstract
Acta Neurol Belg. 2009 Dec;109(4):252-61.
CGRP antagonists: hope for a new era in acute migraine treatment.
Schelstraete C, Paemeleire K.

Department of Neurology, Ghent University Hospital, Ghent, Belgium.
Calcitonin gene-related peptide (CGRP) has a widespread distribution throughout the trigeminovascular system and other brain areas involved in migraine pathogenesis. Serum levels of CGRP are elevated during the migraine attack and return to normal with alleviation of pain. Intravenous injection of CGRP in migraineurs results in delayed headache similar to migraine. Since CGRP receptor antagonists lack direct vasoconstrictor activity, this therapeutic approach may offer advantages over the current mainstay of specific acute migraine treatment with 5-HT1B/1D receptor agonists (triptans), contra-indicated in patients with underlying cardiovascular disease. Intravenous BIBN4096BS (olcegepant) and oral MK-0974 (telcagepant), two CGRP-receptor antagonists, were safe and effective in the treatment of migraine attacks in Phase I and II trials. In a Phase III clinical trial, the efficacy of telcagepant 300 mg was comparable to that of zolmitriptan 5 mg. We intend to review the rationale for the use of CGRP-receptor antagonists, and to outline current developments and future perspectives.

Labels: Calcitonin gene related protein, CGRP antagonist, CGRP migraine, CGRP neuromuscular dentistry, facial pain TMJ, neuromuscular dentistry migraine

An article (PubMed abstract below) in Janury "CRANIO journal" by Dr Wes Shankland dicusses patients with anterior throat pain. These patients have frequently seen numerous physicians and had multiple digagnostic tests and frequently ineffective treatment. There are five syndromes that frequently cause this type of problems. The five disorders are, Ernest syndrome, Eagle's syndrome, carotid artery syndrome, hyoid bone syndrome and superior pharyngeal constrictor syndrome.

Ernest syndrome and Ernst Syndrome are caused by calcification of stylohyoid or stylomandibular ligaments that is frequently diagnosed by panoramic radiographs and palpation of the ligaments. There are numerous cases of throat pain being referred from various muscless but Dr Shankland points to the Superior Pharyngeal constictor syndrome.

According to an article from Tulane (see PUBMED abstract below) a diagnosis of Eagle's syndrome can be difficult to make. The diagnosis is infrequent and the symptoms vary widely.

An excellent description of Eagles Synrome can be found in "South Med J. 1998 Jan;91(1):43." (see PubMed abstract below) "Eagle's syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear". Some of the symptoms of Eagle's Syndrome include:
Pain on turning head
Pain associated with tongue protrusion
Cough without sputum
Voice changes
Symptoms of Sinusitis that do not respon to treatment
Dizziness and/or feelings of disequilibrium, Vertigo
Bloodshot eyes
Throat pain,Throat discomfort Throat soreness or Foreign body sensation in throat
Facial pain
Difficulty swallowing or Dysphagia
Disturbed sense of taste
Headache especially if associated with swallowing
Sensation of excessive salivation
Swallowing difficulty, throat pain associated with swallowing
Pain on opening mouth

Bafaqeeh subclassified Eagle's syndrome into two different types: its classic form and an entity he called styloid-carotid artery syndrome. Symptoms include neurological and vascular problems with at least one report of blindness. The management of styloid-carotid artery syndrome include sagittal CT angiography and/or intraoperative neurophysiologic monitoring, and a transcervical approach to resection.

Many cases of undiagnosed throat pain respond well to neuromucular diagnostic orthotics. When the orthotic and/or trigger point injections do not relieve the pain these other conditions must be explored.


Cranio. 2010 Jan;28(1):50-9.
Anterior throat pain syndromes: causes for undiagnosed craniofacial pain.
Shankland WE 2nd.

TMJ & Facial Pain Center, Westerville, Columbus, Ohio, USA. drwes@drshankland.com
It is not uncommon for practitioners who treat craniofacial pain to see patients with undiagnosed throat and submandibular pain. Usually, these patients will already have been seen by their primary care physician and frequently, several others doctors including otolaryngologists, oral and maxillofacial surgeons, and even neurologists. Far too often these patients have three common features: 1. they have endured multiple expensive diagnostic tests; 2. they have received treatment of multiple courses of antibiotics; and 3. no specific diagnosis for their pain complaints has been determined and their pain persists. In this article, five disorders, Ernest syndrome, Eagle's syndrome, carotid artery syndrome, hyoid bone syndrome and superior pharyngeal constrictor syndrome are briefly described. All five produce common symptoms, making diagnosis difficult, which is often followed by ineffective or no treatment being provided to the patient. Diagnostic criteria and suggested treatment modalities are also presented.

PMID: 20158009 [PubMed - in process]

J La State Med Soc. 1992 Aug;144(8):343-5.
Eagle's syndrome: the Ochsner experience.
Weiss LS, Butcher RB, White JA.

Dept of Otolaryngology-Head & Neck Surgery, Tulane University Medical Center, New Orleans.
Eagle fully described the syndrome that bears his name in 1948. He noted that the typical patient had undergone tonsillectomy in the past. Although reported in the literature, the carotid artery syndrome is frequently overlooked in patients manifesting craniofacial or pharyngeal pain but who have not undergone tonsillectomy. Cases representative of the variety of patients with Eagle's syndrome treated at the Ochsner Clinic Department of Otolaryngology are presented. The diversity of symptoms and its rather uncommon occurrence often make the diagnosis of Eagle's syndrome elusive. The anatomy and embryology of the stylohyoid complex is discussed, as well as the symptoms, differential diagnosis, workup, and treatment of Eagle's syndrome. We hope to refamiliarize the clinician with this condition in order that it be considered in the assessment of patients with craniofacial pain.

PMID: 1453090 [PubMed - indexed for MEDLINE]

South Med J. 1997 Mar;90(3):331-4.
Eagle's syndrome (elongated styloid process)
Balbuena L Jr, Hayes D, Ramirez SG, Johnson R.

Otolaryngology-Head and Neck Surgery Service, Brooke Army Medical Center, Fort Sam Houston, Tex, USA.
Comment in:

South Med J. 1998 Jan;91(1):43.
Eagle's syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear. In adults, the styloid process is approximately 2.5 cm long, and its tip is located between the external and internal carotid arteries, just lateral to the tonsillar fossa. It may develop inflammatory changes or impinge on the adjacent arteries or sensory nerve endings, leading to the symptoms described. Diagnosis can usually be made on physical examination by digital palpation of the styloid process in the tonsillar fossa, which exacerbates the pain. In addition, relief of symptoms with injection of an anesthetic solution into the tonsillar fossa is highly suggestive of this diagnosis. Radiographic workup should include anterior-posterior and lateral skull films. The treatment of Eagle's syndrome is primarily surgical. The styloid process can be shortened through an intraoral or external approach. We present two cases and review the literature.

PMID: 9076308 [PubMed - indexed for MEDLINE]

Labels: eagles syndrome, Ernst syndrome, facial pain TMJ, headache with swallowing, neuromuscular dentistry tmd, pain with swallowing, sore throat, stloid ligament, styloid-carotid artery syndrome, Throat Pain

The diagnosis of facial pain is frequently not called headache pain and often receives a wrong diagnosis. Possible causes of facial pain are TMJ disordrs, trigeinal neuralgia, parotid gland disorders, masticatory muscle pain or pain referred from the cervical an shoulder reasons. Facial pain may resolve easily with neuromuscular dental treatment but it is important to rule out pain of organic nature.

Facial pain and sinus pain are frequently different terms patients use to describe pain referred from muscles which are the easiet pain a neuromuscular dentist treats.

When there is neuralgia pain it is usually sharp, sudden and lancinating and very emotionally charge. I have had patients with trigeminal neuralgia that will protect their trigger area no matter what. It is important to identify triggers that set off this type of excruciating pain. I have seen many patients over the years with neuralgia like pains. Some resonded well to neuromuscular dental treatment immediately while others responded to trigger point injections.

Frequently the area must be calmed down by drug therapy or counter irritants like capascin cream before attempting to place a patient on a TENS unit.

Labels: facial pain, facial pain specialist, facial pain TMJ, Facial pain trigeminal neuralgia, neuromuscular dentistry, trigeminal neuralgia TMJ, trigeminl neuralgia