Question
QUESTION: In 2003, I experienced an onset of constant facial pain after having a wisdom tooth extraction (right side); consisting of burning, tight, and sometimes, lacinating pain.  I had multiple dental procedures done, but all failed. I was then diagnosed with one condition after another, as a result of failed treatments (Trigeminal Neuralgia, Atypical TN, Neuroma, Atypical Facial Pain).  Recently (September), I was diagnosed with TMD/Myofascial Pain Syndrome.  Therefore, I went to a "neuromuscular dentist."  His treatments(TENS, mouth guard, and a one-time trigger point therapy)failed.  The dentist noticed that one leg is shorter than the other, and referred me to a chiropractor; which I sought consultation a couple of weeks ago.  The doctor performed three x-rays and concluded that I  did have leg-length discrepancy and also, my neck deviated to the right (misaligned vertebrae?).  

That same day, the chiropractor used the activator adjusting instrument and we made another appointment to have another readjustment and massage therapy.  Now that I am aware of referred pain, I have noticed that that right side and frontal vertebrae of my neck is very sensitive to the touch, feels inflammed/swollen, and refers pain to my lower/upper right gums.What does this mean? I also have muscle knots on the back/side of my neck and in my chin. I was wondering would adjustment and/or massage therapy relieve the pain?  I'm not sure what sort of treatment to undergo.  I have already lost alot of money on wasted treatments.  I want to make sure I am making the right choices.  Thank you

ANSWER: Lisa,

It sounds like you've been through the ringer...  You have muscles in the front of your neck, and these muscles can refer into the face.  The temporo-mandibular-joint (TMJ) is intimately related to your spine.  Problems with your spine can provoke the TMJ and visa versa.  TENS is a complete waste of time for your condition, and research supports the use of TENS only for chronic back pain people that are in constant pain (not facial pain), and only with the expectation of temporarily lessening the pain, not curing it.  I'd ask the dentist to justify why he uses TENS.  As for "trigger point therapy," the key is to locate a "trigger point."  Lots of practitioners say they do trigger point therapy but have no clue what a trigger point is, or they have no skills or training in finding and alleviating the trigger point.  I have yet to meet a dentist that has skills in this regard, and only have found a few dentists that are knowledgeable in understanding the problem (TMJ specialists who are part of TUFTS Dental TMJ clinic in Boston).   If you have a true trigger point, as defined by the authors Travell and Simons, and further illustrated such authorities such as Dr. Warren Hammer (who wrote a treatise on soft tissue diagnosis and therapy), then that trigger point will duplicate, provoke, or change your facial pain when pressed or massaged.  It would be very difficult to alleviate your pain in one trigger point session, in my opinion, given the information on the duration of your pain.  The Chiropractor must pay close attention to your examining your TMJ's, and must have skills in treating the TMJ's as well as advanced training in treating soft tissues of the head/neck relative to the TMJ's.  He also should work closely with the dentist - preferably a TMJ specialist, not a regular dentist that dabbles in TMJ.  General massage will not likely get at the target tissue if it truly is coming from the front of your cervical spine - this is a very sensitive area close to nerves and nerve ganglia.  Ask the DC to test you with your oral appliance.  Ask if your DC is trained in Active Myofascial Release methods or Graston Technique, and if they ever took a course on TMJ disorders.  If your pain has a mechanical cause from the cervical spine and jaw, then joint manipulation and a properly made appliance should help the symptoms.  If there are trigger points or other myofascial lesions that are part of the equation, then they must be worked out at the same time.  Exercises must be part of your program, and if the DDS or DC cannot provide them, then a PT that is expert with head and neck disorders will be helpful.  I am in favor of looking at other areas of possible dysfunction or mechanical stress, and leg length discrepancy is factor as is asymmetric ankle pronation or arch position.  If your condition is purely a by-product of altered biomechanics and soft tissue irritation, then joint manipulation, soft tissue therapy (including trigger point work), exercises, foot orthotics, and posture/ergonomics should solve your problem in a short period of time.  If you have an arthritic TMJ, truly have trigeminal neuralgia or a neuroma, have psychologic or psycho-social issues, or have an internal illness, then dealing only with your muscles and bones will not solve your problem.   I would suggest finding the right mix of practitioners and use a round-table or team approach to your care.  Ask all doctors to leave their egos at the door...  

'Hope this was helpful.

Dr. G

---------- FOLLOW-UP ----------

QUESTION: I was wondering, which order of steps would you suggest?

1)Solely seek treatment related to TMD, Myofascial Pain,
 and spine disorder.  If none of these treatments work,
  then explore the prospect of internal illness

         
         OR

2) Focus on finding diagnosis/treatment for TMD, Myofascial pain, spine disorder, AND internal illness

*If 1), how long should I wait (for treatment to work)
     before inquiring whether internal illness is the
       cause of pain?

*  Could you give me some examples of what illnesses cause this sort of pain?  Thank you

Answer
Lisa,

#2...  If you have a good TMJ dentist and a good chiropractor, between the two of them odd diseases like tumors or aneurysms will be ruled out.  Also, with blood tests, serologic markers for inflammatory arthritis or infections can be ruled out.  Odds are that your condition is musculoskeletal in nature, and getting the proper mix of treatment is key.  But in case your condition is not musculoskeletal in it's cause, you need doctors to put the puzzle pieces together.   

'Hope this helps.

Dr. G