S4:Ep4 – Self Care Tips for Facial Pain and Headache
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How can we build resilience against mouth, jaw, and face pain? Orofacial pain specialist Dr. James Hawkins offers self-care techniques to help manage both temporomandibular disorder and headache.
Dr. James Hawkins: Hello, everyone. My name is Dr. James Hawkins, and I’m an orofacial pain specialist practicing at the Naval Postgraduate Dental School, where I am the program director for the orofacial pain residency. Today, I want to talk with you about a very interrelated topic, which is TMD and headache. So, to start, I have no disclosures, and, additionally, I have no conflicts of interest.
So we’re going to cover five main points during our brief discussion today. The first one is, I want you to be able to define both orofacial pain and temporomandibular disorders. Next, I’d like you to be able to discuss orofacial pains that can contribute to headache. Third, I want to have you be able to describe the association between TMD and headache. Number four is the most important one for today’s conversation, and that’s I want you to be able to explain self-care techniques that may be beneficial for both TMDs and headaches. And, lastly, I want you to be able to discuss what to do when you have these other conditions that need consultation with a healthcare provider, and I want you to be able to know who to go to.
So let’s start off by defining orofacial pain. Orofacial pain is pain and dysfunction affecting both the sensory and motor transmission in the trigeminal nerve system. So this photo here at the bottom is going to be something you’re going to see a couple times throughout the presentation, and basically it shows you that everything from about the collarbone up that’s painful or fatiguing all goes into a very small, about 12 millimeter area in the brain stem, represented in green there, called the trigeminal subnucleus caudalis. And this area is going to play a key role in why so many different areas of the head, face, neck, and shoulders may cause you to feel headache and how that may be related to orofacial pains and specifically temporomandibular disorders.
Orofacial pains have five broad categories within them. Oral sources may cause an orofacial pain or a headache, such as a carious or cavitated tooth — something many people have experienced. Pathosis — whether it be in the mouth, in the face, or in the brain — can cause someone to have a headache, and that’s a type of orofacial pain. Musculoskeletal pains, which I’ll define in a moment, can cause a headache. Neuropathies or neuralgia, such as trigeminal neuralgia, may cause someone to have a headache and is considered an orofacial pain. And, lastly, headache in and of itself is a type of orofacial pain.
The one I want to focus on mostly today is the musculoskeletal disorders. And TMDs, or temporomandibular disorders, is one of the main musculoskeletal orofacial pains. And, besides toothache, it’s the most common pain complaint someone will be coming to their dentist or doctor for within the facial region.
So, TMDs, according to the American Academy of Orofacial Pain, are defined as a group of musculoskeletal disorders involving the masticatory muscles, some of which you can see on the drawing there; the temporomandibular joint, which is that bony area right in front of the ear, which I’ll show you a close-up of later on; as well as associated tissues. Let’s break that definition down and talk about each different area.
So, first, TMDs may involve the masticatory muscles. So where you see those little black Xs there, that’s the temporalis muscle. And as you can see there, that temporalis muscle can cause pain in certain individuals to be referred up and above the eye and up and through the head, as well as down into the face. The masseter muscle, additionally — that big muscle on the side of the face — can also refer up into the headache region, as well as a number of other muscles. So as you can see in just this brief illustration, different muscles of the face can make you feel a headache.
Or as I showed you in the graphic earlier, coming from the neck, different muscles in the cervical area, or down here, can cause pain to be referred up into the headache. The black X in the illustration on the right shows pain from the trapezius being referred up. So when I evaluate a patient’s headache, I feel around all these different muscle areas from the collarbone up to see if any of those mimic someone’s headache. So I want to see if that TMD may be causing or contributing to why you have pain in your head.
Let’s now move on to seeing why that is interconnected, based on the illustration I showed you earlier. So let’s say the neck is causing the pain, that big trapezius muscle. So you may have a source of pain, such as an injury in that muscle. And as that green area, that trigeminal subnucleus caudalis, becomes sensitized, that can cause you to feel pain other places because the brain gets confused from all the different input. So you may feel pain in your face or in your teeth because of what’s going on in your neck, or you may feel pain up in your head. So the neck may be mimicking the headache, and this is something called myofascial pain or referred pain.
So let’s move on from the musculature into the joint, the TMJ area. So a lot of people think TMJ is a disorder. It’s not. You have two TMJs, right here and here, just like you have two elbows or two knees. The temporomandibular joint — as you can see in the graphic here, or in the video — is bony combination of the temporal bone right here, the mandible — so T-M, the mandible or jawbone — and the J is for joint.
So there’s an illustration of how the normal temporomandibular joint works, and this is a very resilient joint, but, occasionally, for a multitude of reasons, something may become painful in that joint, which can refer up and cause someone to have a headache. So as I’m evaluating the patient, I also press on the TMJ and have the patient do some movements to see is that joint causing or contributing to why someone may have a headache.
Let’s transition on from what TMDs are to who may have TMDs or orofacial pains in general. First and foremost, I want to stress or emphasize that very few people with chronic facial pain have only facial pain. In fact, in our clinic, only 23 percent had just facial pain, whereas about 77 percent had one or more other body pains or uncomfortable conditions. So you can see on the bottom right of this wheel of misfortune that TMD is there, as well as migraine and tension-type headache. But a lot of people who have these conditions also have things like irritable bowel syndrome, interstitial cystitis or bladder issues, multiple chemical sensitivity — where you’re very sensitive to different chemicals or medications, for example — and/or fibromyalgia.
And, basically, all we’re seeing here in the middle of the circle is something called central sensitization. So, in short, your central nervous system, it has become hypersensitive for one or many reasons, and now that’s starting to be expressed in pain in different areas, including the face and/or the head. So I want to make sure I’m assessing patients for pain in other areas.
Additionally, TMDs and headache, as I’m sure you’re well aware of, have a high overlap of depression, anxiety, and sleep disturbance. And it’s going to be really hard to control the pain if we’re not able to start controlling these other areas as well, and that’s why it’s important, if you’re seeing a clinician for your headache or for your TMD, that they’re not just evaluating this area, but they’re taking a biopsychosocial approach. They’re looking at you as an entire person and trying to figure out not only why you’re in pain in the first place, but why aren’t you getting better and what can be done to help you, as a whole person, feel better.
So I want to transition to, I think, the most pertinent topic for today’s presentation and the short time we have together and discuss what are some management approaches for TMDs, which also improves a lot of orofacial pains in general, and this may improve your headache.
So some of the original therapies for TMDs dating back to the ’30s and ’40s — all the way to recently, unfortunately, for some providers — is irreversible therapy to address the TMD. That could be something like orthodontic work or braces, where they put metal brackets on to move the teeth around. It could be reshaping the teeth and putting caps or crowns on all over. Or it could be a surgical procedure, whether that be a surgery in the joint itself or a surgery to fracture and move the mandible. And all these are an effort somehow to bring the teeth in more of an ideal alignment.
But the literature has not supported these as being a primary benefit of TMD patients. It may cause more pain. So, in general, there’s only about 5 percent of people with TMDs that benefit from an irreversible procedure.
Next, we’ll go to the center column, which is doctor-prescribed conservative care. Now, again, I like the word conservative, and there are many things providers can do to help. Things like oral appliances, or splints or night guards are a few of the terms, that — something that goes in your mouth, potentially while you sleep, to help. And while these do benefit some people and they do protect the teeth, the literature has shown they’re not great across the board for the vast majority of patients in helping their orofacial pain complaint. Things like acupuncture injections — all those can be beneficial in some patients as well, but those are all things you need to go back to your provider for. And if you’re a chronic pain patient, often you need to go back frequently to have benefit.
What I want to focus on and emphasize today is the self-care component of your own management. These are things you can do to help this structure up here be in a more neutral, rested position the majority of the day, allowing it to heal on its own, making you more resilient. And that’s a key component, is how do you become more resilient and allow yourself to heal?
And our goals in making more resilient, one would be decrease how much unhealthy input goes in from the periphery, so those lines on the left — the head, face, neck, and shoulders — how much input goes into that brain. So in that brain, we want to decrease unhealthy information in while increasing endogenous inhibition. In other words, I want to increase your body’s own ability to fight pain and feel better. So those are the two goals in all the upcoming slides as I teach you some different ways to improve your resiliency on your own.
So the most important thing I emphasize with almost every patient I see is something called positional awareness training. And another common name for that is habit modification or oral habit modification. So what is that? Well, one, I want you to become aware of unhealthy habits you may be doing with your head and face. As well, we’ll talk about later on your neck and shoulders.
What do I mean by that? Well, first of all, I want to ask you, as someone potentially suffering from headache — or your family member is suffering from headache or TMDs — how many hours a day, if you had to guess, are your teeth touching? How many hours a day are your teeth even resting together gently? Additionally, another odd question that most people don’t think about is how often is your tongue pressed against the roof of your mouth or pressed against your teeth, even gently?
Now, if you’re like a lot of the patients I’ve seen in my clinic, a lot of people are like, “Well, they’re together all the time. Isn’t that where it’s supposed to be?” And, actually, no. I want to have you take your hands here and put them right here, like in the video, and press your teeth together. You feel that muscle contract? Put your hands up here; press your teeth together. You feel that muscle contract? And this one you have to do a little more firmly, but press your tongue nice and firmly to the roof of your mouth. You should be able to feel that contract. And then put your hands here and press your tongue up.
You can feel these muscles contract. So every time your teeth are touching or resting together even gently or your tongue is pressed up, these muscles contract. These muscles are not meant to be marathon runners. They’re not meant to go and go and go all day. They’re meant to be sprinters. They’re meant to run for you 100 meters and then take a break. In other words, they’re meant to chew for you for a few seconds, talk for a few seconds, help you swallow for a few seconds, and then they’re meant to rest. So if you add up all the time throughout the day the teeth should be touching or the tongue should be pressed up against the top of the mouth, it’s milliseconds at a time, totaling about 15 to 20 minutes a day maximum.
Now, I know a lot of you probably have your jaw dropped to the floor now, saying, “Wow, what do I do about this?” Well, that’s what I want to teach you. I want to teach you how to relax these muscles, which decreases how much unhealthy input goes into the brain stem, as well as decreases pressure put on the joint.
And there’s a few different ways to find this. There’s no perfect way that works perfectly for everybody. I’m going to teach you a few different techniques to help you take your teeth apart just a little bit, rest your tongue in the floor of the mouth, and decreases how much tension you hold in your face, putting you in the most restful position possible to allow you to heal.
So the two I like are, one, you can say the letter M or the name Emma, and then relax. “Emma.” And now my teeth are a little apart, my tongue is relaxed in the floor of my mouth, and my face is nice and relaxed. The next one, which I’ll show you an illustration of in a moment, is take one breath of air in your nose and three gentle puffs of air out of your mouth, and then relax. So [inhales], [exhales], [exhales], [exhales]. Again, my teeth are apart, my tongue is relaxed, my face is relaxed.
Let me show you the illustration here. A simple breath in the mouth [sic], and right there you see the teeth are together and tongue’s up. But when you [0:14:12.4 inaudible] separates your teeth and takes your tongue down. If not, you’d be spitting all over the computer screen right now. So, teeth apart, tongue relaxed, face relaxed, either say “Emma” or a breath of air in, three puffs out.
Additionally, even if our teeth are apart and our tongue is relaxed, a lot of us scrunch our face when we’re in traffic or on a computer screen, and we’re not even aware of it. But that can be fatiguing, sending unhealthy input into the nervous system. So gently take your hand down over your face, nice and relaxed as well.
So, again, that’s the position you should be in — in it for health purposes all day, every day when you’re not talking, chewing, or swallowing. But when we’re busy, our brain doesn’t focus on that. So it’s important for us to have a reminder. This can be something like an app, a sticky note, a rubber band, your cell phone timer, your computer on your wrist — your smartwatch — something that cues you about every 30 to 60 minutes for the first couple months during your rehabilitation phase to check. Bing, bing, bing! All right, [exhales], [exhales], [exhales], teeth apart, tongue relaxed, face relaxed.
Having this reminder is essential, because if you don’t, I guarantee you’re going to go right back to doing these habits initially, because we need to retrain the brain and that takes time. So reinforcing the changes in the habit with a reminder helps provide forced rest periods. So instead of running a marathon with these muscles, you’re running a mile, taking a break, running a mile, taking a break, running a mile, taking a break, and you’re improving muscle memory.
Additionally — and we’re not going to go into this much today — but remember the neck muscles can play a role in TMDs and headaches. So make sure you’re using a healthy neck posture, keeping the bowling ball not stretched out in front of you; put the bowling ball right here, which means your head not down here on your cell phone, but your head up here over your cervical spine so you can have this big bowling ball supported by a solid structure.
Other things you can do to help yourself recover is gentle movements, both with the neck and the muscles of the face, to help pump blood flow through these muscles. This is not no pain, no gain. This is slow, controlled, and not over your pain threshold. We want to facilitate recovery, not hurt yourself more.
If you have muscle pain that’s been there for a long time, moist heat can help. So getting washcloths, run them under hot water, and apply them to the face, for example, for three to five minutes, two to four times a day, especially right when you wake up in the morning and right before bed, can really help promote increase in blood vessel size, which promotes blood flow, which removes unhealthy metabolic waste that builds up over time and can become painful, and brings in fresh oxygen and nutrients to facilitate recovery.
Additionally, after that heat, some gentle massage to these uncomfortable muscles can provide benefit and help promote blood flow. If you have a limitation in range of motion or an inability to open your mouth wide, which we didn’t discuss today, some gentle stretching may be beneficial as well. But I would encourage you to consult your orofacial pain provider to discuss that more.
And just be wise with what you’re eating. Don’t do things that hurt. Don’t chew chewy steak or chewy bagels if that causes increased pain. We want to allow these structures to heal. And just like you wouldn’t jump on a sprained ankle, you want to allow these to rest as well. Dr. Okeson, the grandfather of orofacial pain, said 87 percent of simple TMD patients do well with just these conservative methods.
For your reference, here’s an infographic I’ve created, which you’re welcome to take a screenshot of and print off to help remind you of these simple techniques. And at the bottom of that infographic, which I’ve zoomed into here, is a QR code of a little video I put together. You can scan this, and it helps walk you through those simple techniques as well.
We’re not going to go into them today, but there’s lots of other things you likely have already heard about to improve your self-care and improve your own resiliency for headache, which also falls into the temporomandibular-disorder realm as well. So make sure you’re getting the most sleep possible, being physically active without causing increased pain, having a healthy nutrition and adequate hydration, and using evidence-based techniques to keep your reaction to stressors low. All these things are going to be a part of you recovering and feeling better.
Lastly, what I always advise with any type of new pain: seeking a healthcare professional’s advice immediately. If you’ve had your pain for quite a long time — whether that be TMD, another type of orofacial pain, or headache — there are some specific things, while maybe not needing consult initially, would be beneficial to have looked at.
So, very briefly, if you have tooth pain, oftentimes it is coming from the tooth itself. So, by all means, if you have an oral source of pain, go see your dentist to have that looked at. If you note some type of abnormality in the way you move or talk or hear or smell, some cognitive difficulty or difficulty thinking or remembering, or any type of growth in the mouth or outside the mouth, it’s maybe a pathosis. So, by all means, see your dentist or your physician for this.
If you think you have some type of TMD but you feel like you want more information or further evaluation besides this, which I’d highly advise, I’d encourage you to seek an orofacial pain specialist, which is a dentist specializing in orofacial pain. You can go to the American Board of Orofacial Pain, or abop.net, to look for board-certified clinicians that have extra training to help you.
If you have something like a neuralgia or neuropathy, that would be something either an orofacial pain specialist, a neurologist, or even your primary care initially can help you manage. And as you guys already know, if you’re watching this presentation in this format, if you have a headache, there’s a number of appropriate providers you may see to have that evaluated as well.
I want to thank you so much for your time. It’s been great speaking with you, and I hope these self-care techniques can really propel you on to start feeling better.
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