Which Is It--Your Teeth, Your Jaw, Or Your Muscles?

Had a patient come in, complaining of some intense pain in her lower left back tooth that not even medication could help.  My instincts screamed "ROOT CANAL" for the hurting tooth, but I let my doctor brain put the brakes on that line of thinking and I thoughtfully worked through the examination.  In the end, there was no treatment recommended. WHAT?!?!? A dentist doesn't want to carve up a patient?

That scenario is more common than you think. I have treated head and neck pain for years, and I have learned about how pain can be referred from non-tooth sources. Problems with blood vessels, facial nerves, skin, and muscles can elicit tooth pain, and vice versa. These relationships are called bi-directional trigger points. 

Take the example of the primary muscles of chewing.  Not only do we use them to chew, we also use them to clench our teeth in times of stress. Wherever and whatever the nature of the stress (bruxism, apnea to name a couple), our muscles can become inflamed, and pass pain onto the nerve pathways of the teeth. The pictures below will show how upper teeth and lower teeth can be affected.

Conversely, I have anecdotal cases of patients with jaw or muscular or facial pain that is not felt in the teeth, but comes from abscessing, decayed, or inflamed teeth.

I have successfully used bite guards, night guards, Botox in the muscles, and sleep breathing appliances to deal with these aches and pains. 

Building Momentum

I took care of a patient a few months ago who was sweating bullets in my conference room when she saw me for the first time. She couldn't imaging treatment without being "put under."  Now, I don't put anybody to sleep in my clinic, because I simply don't want to assume responsibility for their breathing. But I provided moderate sedation for her, and I have seen her twice for surgeries to replace a tooth with an implant.  Last week, she asked me if I would discuss how to improve her facial esthetics with Botox and Juvederm. WITHOUT sedation.

I thought her progress was interesting, because I have seen a similar pattern in fearful patients. I truly believe that past experiences of traumatic dentistry never fade; those events are hard-wired into the patients' processes of fear and/or anxiety, kind of like a deeply rutted road that is traveled thousands of times. But when I can create a visit that is free of the triggers for that psychological cascade of behaviors, I could swear that a new pathway is created for patients to travel that has a totally different context for them as they sit in my office for consecutive visits.

It's pretty fascinating and rewarding to talk with this patient about how I am going to stick her with a needle, and she is significantly more relaxed. And I proceeded to inject her without anesthesia!!!! Yes, I engineered some trust between us. But that is quite a positive trend she has displayed.  I anticipate she will see me for dental care in the future without the need for sedation, because I see that evolution in other patients too. I like not having to sedate patients. And I like it even more when I know that they can build momentum in a positive way to eliminate that need for sedation care.

Maybe medical insurance...?

We cannot guess what reimbursements exist for medical applications in dentistry. We have to rely on many resources and colleagues to help us over the hurdles when patients ask us to help them wade through the medical claims arena.

We have improve our relationships with medical insurers over the past 5-10 years. We now see a more common reimbursement for temporomandibular (TMJ) therapy, head pain therapy, implant surgery, and a few other services. But it's not a guarantee. Every patient has a different policy with different terms. But we do check, and we notice the climate for medical reimbursement is a bit more sunny for patients than it used to be.

Recently, the pharmaceutical company Allergan invited me to sign on to a Botox reimbursement service. Allergan has counselors who do the homework on behalf of head pain/TMJ patients who want to submit requests for medical reimbursement. The first encounters with the process have been positive.

I was unaware that patients have the potential to receive significant help with payment for Botox therapy as it relates to chronic pain, like migraine, TMJ, and intractable muscular tension pain in the head and neck. WHen I read the summaries from the counselors for my own wife, I was upbeat. There is coverage that can be preauthorized.

So I am inviting patients who want treatment with chronic head, jaw, and neck pain to consult with our office. I always take the position that our patients prepare to make full payment for the therapy. But the potential for reimbursement is more of a reality today.

Botox for Craniofacial and Dental Pain Treatments

Grinding and clenching teeth is caused by a number of disorders. It is usually difficult to stop without intervention.

For most patients, a custom biteguard solves jaw (and sometimes head) muscle pain, eliminates restricted jaw movements, and reduces damage and sensitivity to teeth. In my experience, about 30% of those patients treated with biteguard appliances have continued pain (either migraine- or tension-related head, jaw, and neck pain), dental sensitivity, and continued destruction of teeth and dental restorations.

In our practice, we notice that many patients have daytime tooth clenching or grinding disorders that are difficult to treat with oral appliances; they have to speak with the public or clients, and wearing a daytime device isn't realistic. Other patients we see suffer from sleep breathing disorders. They may have continued jaw, head, and neck pain after undergoing C-PAP or oral appliance therapy. Some patients have chronic migraine headaches pain that aren't relieved by oral appliance alone. All of these types of patients continue to take medications, try other therapies (hypnosis, acupuncture, massage, chiropractic care), and continue to have frustrating pain.

Another category of patients are continual tooth clenchers and grinders without tooth, head, or neck pain, but they repeatedly break dental restorations or teeth. No matter what they do to wear a biteguard, they still destroy things.

There are common threads uniting all of these types of patients. They have a complex disorder called parafunction. (see the preeminent site for information about it here.) Another similarity in all of these patients is how they can treat the problem beyond a biteguard appliance. That therapy involves using botulinum toxin, commonly known as Botox.

Botox has been FDA-approved for use in head and neck pain and dental therapies for years. One of its many benefits is that it reduces the amount of muscle function responsible for head/neck/jaw pain and destruction of dentistry. The other effect of Botox, is that it reduces the long-term activity of these overactive groups of muscles, and can stimulate specific body chemistry associated with healing tissue and likely helps prevent the return of the muscular disorder. (one of many research references may be read here.)

Patients who undergo Botox treatments do not lose muscular control or have total paralysis and loss of motor control. Botox does not make people numb. There is no loss of sensation to touch or feel. The effect of Botox is to temporarily reduce the activity of a group of muscle fibers just enough to prevent the traumatic activity of the muscles from occurring.

Patients who undergo the treatment rarely need anesthesia. They may undergo several treatments, or may choose to have ongoing therapy. It has been found that many patients will undergo several treatments, and find that they do not have pain or destruction that returns after a few treatments. The average amount of the drug for each treatment is about 40-50 units of Botox. Patients can expect to have at least 3-4 treatments. The cost per unit in our practice is $11-13/unit.

Virtually every patient who undergoes Botox therapy needs to have undergone biteguard appliance therapy before Botox is considered. Contact us today to have a free consultation regarding your chronic pain and repeated dental damage.