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Pain & The Immune System

At times we see a patient with TMJ symptoms, but something just doesn’t seem right. Instead of the usual history of most of my patients, which can include tooth grinding and clenching, neck tension, excessive worry and anxiety, and jaw clicking, this patient is experiencing jaw and facial pain for what appears to be no good reason. Jaw motion and function are normal, but pain persists on a daily basis.

A number of these patients have medical histories that include long-term gastrointestinal distress (IBS, Reflux, Gerd, and/or Crohn’s Disease), unexplained skin rashes, and joint pains throughout the body. As a result of these symptoms, they’ve consulted multiple medical specialists who have determined that an underlying autoimmune condition is causing spontaneous inflammatory pain and low pain thresholds.

An Intimate Relationship Between the Immune System & Persistent Pain

There appears to be an intimate relationship between the immune system and the part of the nervous system involved in the experience of persistent pain. Every day your immune system talks to your nervous system (and therefore, your brain) and helps to maintain comfort or sets off alarms if something is wrong such as a virus, infection, dehydration, low blood sugar, etc.

At times, however, people can experience pain because the immune system has told the nervous system that something is wrong – when nothing really is wrong.

It’s become obvious that face and jaw pain can be caused by autoimmune problems. Therefore, the likelihood that traditional treatments, such as jaw exercises, injections, and oral appliances, will fall short. Muscles and joints may only be the site of your symptoms but not the direct cause.

We treat many patients with autoimmune problems. We depend on the strong relationships we have with our physician colleagues in rheumatology and immunology to help these patients with a great deal of success.

If you or someone you know is experiencing persistent or acute pain in the face or jaw, we invite you to set up a consultation with one of our Orofacial Pain specialists in the NYC metropolitan area. Our office locations and contact information are below.

What is referred pain?

The concept of referred pain has been around for over 50 years. It is used to describe the phenomenon of pain experienced at a site nearby or even at a distance from the pain’s origin.

It’s likely you have heard that one of the most common symptoms of a heart attack is pain in the left arm or shoulder. This is a pattern of referred pain.  Fortunately, this pattern of symptom description is now well recognized, allowing medical professionals to deliver care to the right place  – the heart – instead of the wrong place – the arm!

In the face, mouth, and jaw, the experience of referred pain is common. Routinely we see patients with tooth pain, gum pain, jaw pain, and ear pain when in fact, the origin of the pain symptom is coming from elsewhere. Unfortunately, patients choose the doctor they visit based on the symptom location, and this can produce a great deal of confusion and, at times, treatment directed at the wrong place.

At first, the examining doctor has no choice but to look at the site of the pain complaint, but if no findings are uncovered, the thinking of the doctor must change and focus on possible sources of referral.  When the focus is not changed, treatment is delivered without success leading to patient frustration.

Though the neurologic basis behind referred pain is complicated, there are several things to understand.

• Referred pain typically does not cross the midline. If the problem area generating the pain is on the right side of the body, the pain that is experienced is also on the right.
• It is most common for referred pain to move upwards in the body. That is, pain is typically referred from the neck and shoulder to the face and jaw, not vice versa.
• Not surprisingly, if the location of the pain experienced is treated and the origin is neglected, the pain will continue.
• Though muscles are involved in the majority of referred pain problems that we see, blood vessels and nerves can also be involved in pain referral leading to more comprehensive evaluations.

 

As you can imagine, referred pain is often a difficult and challenging problem for patients and physicians. As a result, our evaluation is always focused on the sources of possible referral, not just on where the symptoms are focused.

If you or someone you know is experiencing persistent or acute pain in the face or jaw, we invite you to set up a consultation with one of our Orofacial Pain specialists in the NYC metropolitan area. Our office locations and contact information are below.

Facial Pain Problems: Why So Many Women?

 

In my practice, we see 4 distinct categories of facial pain problems.

• Muscle and joint pain problems
• Nerve pain problems
• Tension Headache and Migraines
• Chronic widespread pain (formerly called fibromyalgia)

It would seem that these problems could affect anyone, but in fact, the vast majority of patients that walk through the door of our practice are women. Believe it or not, somewhere between 78% and 82% of all the patients we see are female.

 

In the past, this dominance of women was attributed to social and cultural factors that prompted women to seek care more frequently than their male counterparts. Though women do seek care more frequently than men for a number of medical problems, research in pain biology has provided evidence that there are unique factors that are likely driving this huge statistical difference, particularly in the face and jaw.

 

The Estrogen Connection

 

One big biologic difference between men and women relates to the hormone estrogen. Studies have shown that variable levels of estrogen not only have the ability to impact the effectiveness of the body’s endorphins (our natural pain fighters) but can also increase inflammation associated with the Temporomandibular Joints (TMJ). During times of persistent stress, compromised sleep, and monthly menstrual cycles, estrogen levels fluctuate sufficiently to prompt pain to emerge in unexpected ways not commonly seen in men.

 

As estrogen is known to compromise the strength and adaptive capacity of ligaments throughout the body, the TM joints are a common location for problems to surface. As a result, the supportive jaw ligaments in women are likely to become more readily compromised when subject to the forces of normal function and certainly to excessive functions like gum chewing, nail and cuticle biting, and clenching or grinding of the teeth. As a result, symptoms of jaw clicking, popping, and locking are more likely to occur, persist and escalate in women when compared to men.

 

Also, when considering the biologic differences between men and women, it is worth mentioning that the jaw muscles of men have greater endurance than similar muscles in women. This likely occurs as the jaw muscles of women receive less blood flow (and therefore less oxygen and nutrients) than the same muscles in men, making them more susceptible to tiring more easily during both normal and excessive jaw use.

 

As a result, as oxygen levels in muscle tissue drops, the chemical makeup of the muscle changes with lactic acid and other irritating substances accumulating over time. These chemical changes lead to muscle soreness initially and then muscle weakness and susceptibility to spasms as time passes. These factors, therefore, may be responsible for the predisposition women have to developing facial and jaw pain and problems associated with jaw motion.

 

In attempting to understand why women have much more profound pain experienced in the Temporomandibular joints, the impact estrogen potentially has in increasing the intensity and persistence of inflammation cannot be overlooked. Specific estrogen receptors in the TM joints of women must, therefore, not be overlooked when trying to understand the predisposition of women to these often debilitating problems.

 

Migraines, Continuous Nerve Pain & Chronic Widespread Pain

 

Within this category of diverse sufferers, we again see a female dominance. Though the reasons for the onset of these very different pain problems in all individuals are not fully understood, there is evidence that each of these pain problems, to some degree, is connected to lowered nerve firing thresholds. Research has, in fact, suggested that these lowered nerve-firing thresholds that lead to pain are the result of an individual’s genetic makeup (an individual’s phenotype) and or due to changes in an individual’s genetic makeup due to environmental influences. These are called epigenetic changes. One or both of these factors are often responsible for changes in the way the brain interprets sensory signals received from all parts of the body.

When normal sensory signals received from bodily tissues are interpreted as noxious, an individual becomes predisposed to pain problems. As over 60% of all sensory information reaching the brain comes from the oral and facial region, women who more commonly have these genetic or epigenetic profiles will suffer to a greater extent whether the initiating factors were traumatic events of all degrees, environmental challenges, sleep compromises and/or life stressors of all types.

 

As the medical community begins to understand this biologic predisposition to facial pain and jaw-related problems, women who come to my office are not categorized as complainers who can’t handle life’s tensions and challenges. Rather, we understand the complexity of these problems and don’t blame the person. We focus on putting the best treatment strategies together that will confront not only the pain-prompting biology but also the person who is in trouble.

 

With the success that we have achieved over the years, you should be optimistic that there are answers to your problems.

If you or someone you know is experiencing persistent or acute pain in the face or jaw, we invite you to set up a consultation with one of our Orofacial Pain specialists in the NYC metropolitan area. Our office locations and contact information are below.

What Parents Should Understand About TMJ/TMD Problems

Though you may have been told that your child has TMJ –  so does every other child! TMJ, when spelled out, stands for the temporomandibular joint, which is a body part – not a disease.

 

That being said, the TM joints, like all other joints, can become compromised. As a result, pain can be experienced along with limited jaw motion, joint noises during motion, and changes in the way the teeth come together. These symptoms together are known as a TMD problem. Patients with a TMD problem often also experiences headaches, jaw muscle tension and soreness, ear symptoms (such as pain and fullness), and a locked jaw (some call this lockjaw, although that is a different clinical problem).

 

An accidental injury to the jaw or underlying medical problem can lead to sudden joint inflammation and pain, as well.

 

But for most children, adolescents, and teens, TMD problems come on slowly. It’s important to understand that the most common cause of TMD problems in young people is consistent overuse behaviors such as gum chewing, nail/cuticle biting, or teeth grinding and/or clenching. Overuse behaviors are commonly driven by the life tensions and worries that accompany school and peer pressure and home stressors that are challenging (and unavoidable).

 

TMJ problems often result in headaches that are located in the temples and forehead. For some kids, these headaches are so disruptive that school performance is impacted, and they must take pain medications on a daily basis.

 

Many young patients arrive at our practice who have previously undergone extensive medical workups to rule out serious disease as a cause of their problems. Yet, their pain continued.

 

If your child fits the above description, we can help. Our over three decades of experience focused on jaw and neck muscles is key to identifying why your child continues to suffer, in spite of nothing serious having been detected before.

 

Sleep and TMD Problems in Children

 

A history of poor sleep quality and quantity is frequently uncovered in our young patients. Eight hours is the prescribed amount of sleep for growing kids, but many of them fall short by two to three hours a night on a routine basis. School workloads, after school activities, late-day caffeinated beverages, online temptations, and use of prescription stimulants during the day all can have a profound impact on sleep.

 

Over the years, we have discovered that poor sleep can lower patient pain thresholds and give rise to headaches, muscle pain and prompt increased levels of teeth grinding and clenching.

 

Orthodontics and TMD

 

We see many parents who are concerned that orthodontic treatment could aggravate their child’s pre-existing TMD problem. And many ask whether ongoing or recently completed orthodontics could be a factor in the onset or escalation of their child’s jaw symptoms.

 

These questions have to be carefully assessed and require not only an understanding of tooth movement and how the jaw functions but an equal understanding of the patient who is worried about moving forward with orthodontics or is already having trouble. The knowledge that TMD problems occur when muscles, ligaments, tendons, and joint tissues become compromised, we can figure out if moving the teeth will (or has already) upset the balance required for comfort to be maintained.

 

The goal of orthodontics is to achieve both improved function and better aesthetics. How those two goals are achieved can often determine whether a person’s jaw structures remain stable both in the short- and long term. When faced with these scenarios, collaboration with our orthodontic colleagues is an essential part of our ability to address often complicated problems.

 

Yes, children can (and do) suffer from TMJ problems. If you suspect your child is one of them, you’re in the right place.

If you or someone you know is experiencing persistent or acute pain in the face or jaw, we invite you to set up a consultation with one of our Orofacial Pain specialists in the NYC metropolitan area. Our office locations and contact information are below.