OPINION The headache of temporomandibular disorders J. Virdee1 In brief Recaps the key guidelines for the diagnosis and Discusses the role of the general dental practitioner Highlights the challenges presented by facial pain for management of temporomandibular disorders in facial pain disorders. patients and clinicians. (TMD). This article endeavours to revise the key guidance and evidence on temporomandibular disorders (TMD), with a particular focus on myofascial pain. It highlights the important role that primary care dental practitioners play in providing holistic care during the patient’s journey to manage this painful condition. I hope to give an insight into my own personal experiences to highlight the challenges patients can face in seeking appropriate support. Introduction was worse on hot or cold, but I had never met treatment. I had a personal insight into how a patient with non-odontogenic pain. frustrating a predicament this can be for patients Imagine pain in your face – a difficult concept It was unexpectedly that the pain in my face and felt determined to widen my own if you have never truly experienced it. From suddenly began. I visited a local dentist who knowledge on the subject of facial pain. During early in my dental career, I have realised that informed me that as this was out of his remit my undergraduate placements and now in my dentists and pain are a common patient asso- of care, he was unable to offer any advice. I dental foundation training year, temporoman- ciation. Individuals attending with toothache had not revealed that I was in fact a final year dibular disorder (TMD) seems to be a prevalent can expect to leave with a relief of their dental student at the time and clearly recalled facial pain condition, which unlike sinusitis, symptoms, possibly with a pulp extirpation that pain of non-dental origin featured in my appears to have a greater tendency for chronic- or extraction. The challenge with facial pains lecture timetable. I felt a loss of faith in the ity of symptoms. This particular feature of the and of particular interest, myofascial pain, is dental profession, saddened to contemplate condition can pose great challenges to dental the difficulty in identifying a causative factor. that dentists only feel comfortable treating professionals and patients in managing the pain The pathophysiology of the condition, with teeth. Sat on the other side of the dental chair, symptoms and hence, formed the focus of my its potential for chronic disposition, further now as a patient, I was confused on whom to interest. An informative basis for management complicates the management strategy. There is turn to next. of these conditions can be found by The Royal no ‘quick fix’ for pain relief. Patients will likely I left the surgery disheartened and decided College of Surgeons (RCS), which suggests a return with pain. to contact my general medical practitioner, review paper providing guidance from the UK As dentists, we deliberate much over the dif- hoping that a clearer diagnosis would be Specialist Interest Group in Orofacial Pain and ferential diagnosis of pulpal pain, but beyond made. This soon seemed an unrealistic expec- Temporomandibular Disorders.1 This, alongside this, I question how confident a dentist would tation as, again, no definitive diagnosis was guidance published by the National Institute of feel assessing pain of non-dental origin. This made and I was sent home with an antibiotic Health and Care Excellence (NICE), forms the view is likely due to an experience more close to prescription. Unsurprisingly, the antibiot- basis of this recap on managing TMDs.2 home. My personal experience with facial pain ics proved unhelpful in improving my facial could be considered an unusual case. For the pain symptoms. I was genuinely worried Demographics majority of my time at dental school, facial pain and alarmed as to what could possibly be was a phenomenon I understood theoretically happening. After weeks of various medical TMD has been proposed as the third most in lectures and textbooks. I was well rehearsed consultations, a simple sinusitis was identi- common chronic pain disorder but one should in investigating with patients if their toothache fied. Thankfully, this self-limiting condition consider that not all symptomatic patients may resolved spontaneously. present for treatment.3 Dental income protec- University of Liverpool Graduate and Foundation Dentist The experience, however, highlighted the tion provider Dentists Provident, claims that Correspondence to: Jaspreet Virdee worrying dilemma that my own patients may over a third of their claims paid to members in Email: [email protected] face in seeking help for facial pain, consulting 2013 were due to musculoskeletal disorders.4 Refereed Paper. Accepted 7 November 2017 different health professionals, with confusion It is also worth considering that The Health DOI: 10.1038/sj.bdj.2018.42 over the diagnosis and delays in appropriate and Safety Executive reported that in 2016, a BRITISH DENTAL JOURNAL | Advance Online Publication | JANUARY 19 2018 1 Official j ournal of the British Dental Associati on. OPINION staggering 8.8 million working days were taken to blame. A further theory suggests otalgia have much influence on treatment planning. off at the hands of musculoskeletal problems.5 occurs secondary to a ligamentous connection In any case, the use of ionising radiation as a Musculoskeletal conditions, such as TMD, between the temporomandibular joint and the special investigation in TMD must have a clear have a clear potential to significantly impede middle ear canal.8 justification.1 the ability to perform daily activities. A headache disorder or TMD mimicking a When forming a diagnosis, it should be headache is a challenging distinction to make. established whether a muscle, disc or joint Obtaining a history The two may also exist simultaneously. The disorder exists. Systemic conditions may be International Headache Society provides a of significance, including fibromyalgia and Even if you are referring onwards, obtaining comprehensive classification of primary and rheumatoid arthritis which may have a TMD a detailed history is valuable in aiding other secondary headaches, cranial neuropathies and component.1 Once a diagnosis has been clinicians in reaching an appropriate diagnosis other headache disorders.9 The classification made, a treatment plan can be constructed as and helps track changes in symptoms which advises that disorders of the cervical spine and appropriate. could be clinically significant. It is important to other structures of the head and neck cannot appreciate that the RCS highlights the need to be excluded as potential causes of headache. Management in primary care make a psychosocial assessment of the patient.1 A headache may originate from the cervical, Making this assessment is vital to holistic care nuchal or occipital regions or may be localised Acute TMD of muscular origin may follow of the patient and could be approached by to these regions.9 Headaches are cervicogenic dental treatment such as a lower third molar investigating the social history and utilising in nature if causally associated with cervical extraction resulting in acute pain and limited pain scales to establish the effect TMD is myofascial pain sources, also known as myo- mouth opening. At this stage, the damage is having on life.6 It is easy to completely under- fascial trigger points. The headache is caused still within the biopsychosocial reparative estimate the impact of this facial pain disorder. by a disorder of the cervical spine and its bony, capacity. A soft diet, resting the jaw and anti- Normal daily activities such as eating well, can disc or soft tissue components and may also inflammatory analgesics such as ibuprofen, easily become adversely affected and have a be accompanied by neck pain. Evidence of should be advised.1 secondary impact on the overall wellbeing of causation may be demonstrated by a reduction The use of paracetamol in a stepwise manner our patients. in cervical range of motion and a worsening of alongside non-steroidal anti-inflammatory Extra-oral and intra-oral examinations are the headache on provocation of the myofascial drugs (NSAIDs) may be helpful.1 The full essential to any diagnosis being made. The trigger point. Accordingly, the headache is analgesic action of NSAIDs is obtainable face should be carefully assessed for asym- eliminated following a diagnostic block of the within a week, however, it may take as long as metries or swelling and any neurological signs cervical structure or its nerve supply.9 three weeks for the anti-inflammatory action or symptoms will necessitate the need for a Localised areas which cause exacerbation to take effect.11 All NSAIDs have the potential cranial nerve examination. Parafunctional of the patient’s pain on palpation may be con- to cause adverse gastrointestinal effects. Those habits must be noted and investigated. The sidered potential trigger points. Local anaes- with a low risk for these effects, for example TMJ should be palpated and assessed for thetic injections into these muscular trigger ibuprofen, should be preferentially selected, tenderness, range of movement, pain, mouth points may reduce or resolve the pain and can starting at the lowest recommended dose.11 opening and joint noises or crepitus. Likewise, be diagnostic in assessing whether a referral Topical ibuprofen over the muscle may limit the muscles of mastication should be palpated pattern truly exists. Longer acting anaesthet- systemic effects and provide direct relief.1 The to assess for tenderness, hypertrophy or the ics may induce inflammation and coagulation use of a short course of diazepam to assist presence of trigger points.1 This assessment necrosis of muscle tissue, a factor which must muscle relaxation may be considered in an should extend to other muscles of the head and be included in the consent process with the acute phase. Benzodiazepines are susceptible neck including scalene, sternocleidomastoid patient.