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PTSD AND OROFACIAL PAIN – A Case Study

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

Date: July 23, 2019

Identifying the origin of a patient’s chronic orofacial and TMJ pain is what makes my work both challenging and rewarding. Sometimes the answers are readily apparent while at other times uncovering important clues is more difficult. In all cases, there is no substitute for obtaining a careful history as the insights gained often help point to the mechanism of pain that is driving a patient’s suffering.

With this thought in mind, I’ve treated numerous patients whose chronic orofacial and TMJ pain is the result of unresolved trauma to the nervous system. A careful history, however, reveals that this trauma is not because of a physical event such as a documented injury or ongoing activities such as nighttime bruxing, but instead, it is the result of personal anguish.

This anguish may arise when a patient no longer has control over an aspect of their life when a patient harbors a belief that there is no resolution to a grim situation, or when a patient yearns to escape a potentially dangerous environment. These scenarios are commonly associated with individuals diagnosed as having PTSD.

For me, these patients are like our servicemen and women returning from deployment overseas. Although in my practice, military service is not the most common source of patient problems, those presenting for care need just as much understanding and support as our soldiers.

 

How PTSD Affects The Nervous System

As a result of a single event or persistent assaults over time, the nervous system will go into survival mode. The sympathetic nervous system is thrust into what is called the hyperactive state. This condition over an extended length of time causes stress hormones to be released, particularly cortisol.

As a result, we see a rise in both blood pressure and blood sugar, resulting in biologic changes that can undermine healing and lead to chronic pain. Particularly in muscles that are already overworked or tense. In this state, tissue injury often occurs and is accompanied by symptoms such as pain, restricted motion in joint systems, muscle cramping, and muscle fatigue.

If a patient’s medical history also includes previous problems such as migraines, neck pain, or back pain – they invariably get worse. When the pain becomes persistent, feelings of anxiety, hopelessness, and depression can emerge.

A patient in this condition has less capacity to respond to stressful situations, and that fact alone creates even more life challenges. These features define the PTSD patient.

 

PTSD & Orofacial Pain – A Case Study

“Jill” is a 39-year old woman who presented for care to address ongoing jaw pain, tension, and limited jaw motion. A detailed history made it clear that her symptoms were the end result of muscle and joint tissue compromise. An examination confirmed the diagnosis of muscle guarding, spasm, and joint inflammation.

Jill was experiencing enough stress in her life to provide fuel for her ongoing symptoms. Faced with the overwhelming pressure of raising her medically-compromised child and constant worry about the future, she had been living in a continuous flight-or-fight mode for years. 

The impact of Jill’s stressful daily life was demonstrated by her raised shoulders, quick, shallow breathing, and a daytime tendency to brace her jaw muscles or contact her teeth for minutes, even hours, at a time.

With the absence of any other factor that could be responsible for her symptoms and with the knowledge of her life situation, I set out to provide insights and create a plan of treatment. All with the knowledge that Jill’s life “stressors” were not going to go away anytime soon.

 

CAN WE HELP THESE PATIENTS?

So the question is, can tissue heal and symptoms diminish in a patient like Jill, who is trapped in a stressful life?

The road is not easy, but by getting patients to participate in meditation, Cognitive Behavior Therapy (CBT), psychotherapy, and physical therapy, benefits can and will be realized. The important word, of course, is participate.

That is often easier said than done, particularly over a long period of time.

Beyond those formal components of care, what may be more useful is a daily commitment by the patient to identify daytime behaviors such as jaw bracing, tooth contact, breath-holding, and shoulder raising, for instance, that may be fatiguing the jaw and neck muscles.

Once identified, a focus on using a variety of breathing exercises, like Buteyko breathing to relax the jaw and neck muscles, is critical. As focused, controlled breathing has been shown to change oxygen and carbon dioxide ratios in the blood; these techniques can often lead to healing opportunities.

In addition, the integration of a 20-minute Tai Chi exercise program into a pain patient’s life three times a week can also lead to profound biologic changes that support pain relief.

For Jill, pain relief was not realized quickly, but by employing a number of these strategies, she continues to be “much better than the day I met her.” She takes much less over-the-counter pain medication, sleeps more soundly, and most importantly, has optimism and hope that a better day is coming.

However, it is important to remember that although it is often impossible to change a patient’s environment, changes can be made to the way people exist within that environment. This can lead the way to unravel the complexities of PTSD and its associated symptoms.

I welcome your thoughts.

Donald

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