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Chronic Orofacial Pain The 60/40 Rule For
Treatment Success

Author: Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain

Date: November 16, 2017

Every morning upon my arrival at work I glance at the list of patients due to be seen that day. My patients are primarily people who seek treatment for chronic orofacial pain. Some of them will be scheduled for a follow-up assessment and/or treatment. Others are first-time patients who seek answers to a problem that has recently emerged. And some are looking for answers to a chronic problem that has lingered despite self-directed care and/or prior interventions by other medical, dental, and health care providers.
With the knowledge that many of these patients suffer from headaches, muscle- and joint-related jaw disorders, persistent and stubborn toothaches, and/or nerve pain disorders, you would be right to assume that the treatment options for each would be very different. In some ways that thinking is accurate. To care for each of these problems the treatment choices and sequencing will vary to a considerable extent.
However, if success is to be realized there is one crucial element that must be considered. I call it The 60/40 Rule in the treatment of chronic orofacial Pain.

The 60/40 Rule In The Treatment Of Chronic Orofacial Pain Explained

The 60/40 Rule is this: the patient and the provider must share the responsibility of implementing the care plan. Sometimes the patient will do 60% of the work and the provider will do 40%. Sometimes that will be reversed. It all depends upon the nature of the patient’s problem.
I allude to this concept in my book Doctor, Why Does My Face Still Ache? Many of my colleagues who devote their energies to treating TMJ and chronic orofacial pain patients also embrace this concept.
However, recently at a conference sponsored by the American Academy of Orofacial Pain it was asserted by one of the keynote speakers that an 80/20 Rule in regard to the treatment of chronic orofacial pain is the correct ratio. In his mind the patient should be responsible for 80% of the work and the provider for 20%.
Though this an understandable goal, clinical research, which has consistently concluded that only 25% of chronic pain patients will only do 50% of what is required to make progress this 80/20 Split appears to be an unlikely reality
In my practice The 60/40 Rule has been most helpful when treating patients with facial and jaw pain of muscle/ joint origin, often called TMD problems. The origin of their problems is related to persistent tightness and fatigue of the jaw and neck muscles combined with overuse-driven instability of the temporomandibular joints.
A multitude of risk factors are most often associated with these problems which include life circumstances, tension, emotions, acquired behaviors, food selections that overwork the muscles and TM joints, habitual and work-related postures, poor breathing dynamics, and loss of sleep quantity and quality. Taken all together you can readily see how The 60/40 Rule of shared responsibility makes sense.
Thankfully, I have an arsenal of treatment selections at my disposal to help patients get relief from chronic orofacial pain. Here are some of them:
  • Postural retraining
  • Daily home exercises
  • Home muscle massage
  • Elimination of destructive daily behaviors and habits
  • Diaphragmatic breathing strategies
  • Formal meditation training
  • Movement therapies such as Feldenkrais or The Alexander Technique
  • Improvement in sleep quantity and quality
  • Medication
  • Oral appliances that support and rest muscle and joint injuries
This collaborative approach between the patient and the provider is essential for success. When the responsibility is shared, patients own their successes and in addition, are more open to share their disappointment if treatment fails.
The 60/40 Rule in chronic orofacial pain treatment ensures that patients are fully engaged in their own treatment and this sets providers free from an expectation that they are fully responsible to fix or cure a chronic problem that may not have an easy solution. The 60/40 Rule must be explained at the outset of treatment when both patient and practitioner are the most focused on the challenges that lie ahead. This is particularly true if the patient has experienced treatment failure in the past.
As new knowledge indicates that chronic pain problems are best treated with interventions that confront the nervous system, the immune system, and the emotional brain, a collaborative approach to care is now even more critical. Patients and providers that embrace The 60/40 Rule will be the beneficiaries of treatment that is both successful and lasting.
I welcome your comments or questions.

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