H. Gremillion-Temporomandibular Disorders and Orafacial Pain, An Issue of Dental Clinics (The Clinics - Dentistry) - Saunders (2007) PDF

Dent Clin N Am 51 (2007) xixii
Preface
Henry A. Gremillion, DDS

Guest Editor
Since the last issue on temporomandibular (TMD) disorders and orofa-

cial pain presented in the Dental Clinics of North America (April 1997), there
has been an explosion of scientic, technologic, and procedural advances in
this complex eld. The amalgamation of the science with the art of dentistry
has resulted from an enhanced appreciation for and the ability to provide
evidence-based diagnosis and care.
Pain and compromised function are the most common reasons for which
people seek health care. Historically, dentistry has been most eective re-
garding the diagnosis and management of acute pain conditions. However,
more than one in four Americans, approximately 75 million people, live in
chronic pain. Many of these individuals experience pain in the orofacial
region. Our role as diagnosticians, becoming physicians of the masticatory
system and orofacial area, is more important than ever. We must develop
an increased clinical awareness of pain and its many facets. For example,
we now appreciate that diagnosis of painful conditions involving the head
and neck is frequently complicated by referred pain or co-existing condi-
tions that may lead the practitioner down a path of well-intentioned but
misdirected care.
Our profession is at the forefront in the establishment of a new and
expanded mind-set reected in the clinician/scientist model. Dentistry must
assume the role of leader in the eld of diagnosis and management of pain
and dysfunction in the most complexly innervated area of the human body,
the stomatognathic system and its contiguous structures.
0011-8532/07/$ - see front matter 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2006.10.004 dental.theclinics.com
xii PREFACE
As guest editor, I wanted to provide a forum in which the many facets of

orofacial pain would be presented. The broad scope and depth of informa-
tion contained in this issue is testimony to the rapidly and ever-expanding
body of clinically relevant information in the eld of TMD and orofacial
pain. I wish to thank the authors for their excellent eort and cooperation
in putting this volume together. I am especially grateful to John Vassallo,
editor of the Dental Clinics of North America, for his patience, support,
and guidance.
Henry A. Gremillion, DDS

Department of Orthodontics
Parker E. Mahan Facial Pain Center
University of Florida College of Dentistry
PO Box 100437
Gainesville, FL 32610-0437, USA
E-mail address: [email protected]
TEMPOROMANDIBULAR DISORDERS AND OROFACIAL PAIN
CONTENTS
Preface xi
Henry A. Gremillion
Overview of Orofacial Pain: Epidemiology and Gender

Differences in Orofacial Pain 1
Rene M. Shinal and Roger B. Fillingim
Chronic orofacial pain is a prevalent problem that encompasses
numerous disorders with diverse causes and presenting symp-
toms. Compared with men, women of reproductive age seek treat-
ment for orofacial pain conditions, as well as other chronic pain
disorders more frequently. Important issues have been raised
regarding gender and sex differences in genetic, neurophysiologic,
and psychosocial aspects of pain sensitivity and analgesia. Efforts
to improve our understanding of qualitative sex differences in pain
modulation signify a promising step toward developing more
tailored approaches to pain management.
Peripheral Mechanisms of Odontogenic Pain 19

Michael A. Henry and Kenneth M. Hargreaves
In this article, we review the key basic mechanisms associated with
this phenomena and more recently identified mechanisms that are
current areas of interest. Although many of these pain mechanisms
apply throughout the body, we attempt to describe these mechan-
isms in the context of trigeminal pain.
Central Mechanisms of Orofacial Pain 45

Robert L. Merrill
The orofacial pain clinician must understand the difference
between peripheral and central mechanisms of pain. Particularly,
one has to understand the process of central sensitization as it
relates to the various orofacial pain conditions to understand
orofacial pain. Understanding leads to more effective treatment.
VOLUME 51 NUMBER 1 JANUARY 2007 v

Myogenous Temporomandibular Disorders: Diagnostic
and Management Considerations 61
James Fricton
Myogenous temporomandibular disorders (or masticatory myal-
gia) are characterized by pain and dysfunction that arise from
pathologic and functional processes in the masticatory muscles.
There are several distinct muscle disorder subtypes in the mastica-
tory system, including myofascial pain, myositis, muscle spasm,
and muscle contracture. The major characteristics of masticatory
myalgia include pain, muscle tenderness, limited range of motion,
and other symptoms (eg, fatigability, stiffness, subjective weak-
ness). Comorbid conditions and complicating factors also are
common and are discussed. Management follows with stretching,
posture, and relaxation exercises, physical therapy, reduction of con-
tributing factors, and as necessary, muscle injections.
Joint Intracapsular Disorders: Diagnostic and Nonsurgical

Management Considerations 85
Jeffrey P. Okeson
This article reviews common intracapsular temporomandibular
disorders encountered in the dental practice. It begins with a brief
review of normal temporomandibular joint anatomy and function
followed by a description of the common types of disorders known
as internal derangements. The etiology, history, and clinical presen-
tation of each are reviewed. Nonsurgical management is presented
based on current long-term scientific evidence.
Temporomandibular Disorders: Associated Features 105

Ronald C. Auvenshine
Temporomandibular disorder (TMD) encompasses a number of
clinical problems involving the masticatory muscles or the tempor-
omandibular joints. These disorders are a major cause of nondental
pain in the orofacial region, and are considered to be a subclassifi-
cation of musculoskeletal disorders. Orofacial pain and TMD can
be associated with pathologic conditions or disorders related to
somatic and neurologic structures. When patients present to the
dental office with a chief complaint of pain or headaches, it is vital
for the practitioner to understand the cause of the complaint and to
perform a thorough examination that will lead to the correct diag-
nosis and appropriate treatment. A complete understanding of the
associated medical conditions with symptomology common to
TMD and orofacial pain is necessary for a proper diagnosis.
Temporomandibular Disorders and Headache 129

Steven B. Graff-Radford
Headache is a common symptom, but when severe, it may be
extremely disabling. It is assumed that patients who present to
vi CONTENTS
dentists with headache often are diagnosed with a temporomandib-
ular disorder (TMD), although many may have migraine. TMD as
a collective term may include several clinical entities, including
myogenous and arthrogenous components. Because headache and
TMD are so common they may be integrated or separate entities.
Nevertheless, the temporomandibular joint (TMJ) and associated
orofacial structures should be considered as triggering or perpetuat-
ing factors for migraine. This article discusses the relationship be-
tween the TMJ, muscles, or other orofacial structures and headache.
Psychological Factors Associated with Orofacial Pains 145

Charles R. Carlson
This article develops the case for why trigeminal pain is a unique
and challenging problem for clinicians and patients alike, and
provides the reader with insights for effective trigeminal pain
management based on an understanding of the interplay between
psychologic and physiologic systems. There is no greater sensory
experience for the brain to manage than unremitting pain in
trigeminally mediated areas. Such pain overwhelms conscious
experience and focuses the suffering individual like few other
sensory events. Trigeminal pain often motivates a search for relief
that can drain financial and emotional resources. In some instances,
the search is rewarded by a treatment that immediately addresses
an identifiable source of pain; in other cases, it can stimulate never-
ending pilgrimages from one health provider to another.
Temporomandibular Disorders, Head and Orofacial Pain:

Cervical Spine Considerations 161
Steve Kraus
Head and orofacial pain originates from dental, neurologic, muscu-
loskeletal, otolaryngologic, vascular, metaplastic, or infectious
disease. It is treated by many health care practitioners, such as
dentists, oral surgeons, and physicians. The article focuses on the
nonpathologic involvement of the musculoskeletal system as a
source of head and orofacial pain. The areas of the musculoskeletal
system that are reviewed include the temporomandibular joint and
muscles of masticationcollectively referred to as temporoman-
dibular disorders (TMDs) and cervical spine disorders. The first
part of the article highlights the role of physical therapy in the
treatment of TMDs. The second part discusses cervical spine con-
siderations in the management of TMDs and head and orofacial
symptoms. It concludes with an overview of the evaluation and
treatment of the cervical spine.
Temporomandibular Joint Surgery for Internal

Derangement 195
M. Franklin Dolwick
Surgery of the temporomandibular joint (TMJ) plays a small,
but important, role in the management of patients who have
CONTENTS vii
temporomandibular disorders (TMDs). There is a spectrum of sur-
gical procedures for the treatment of TMD that ranges from simple
arthrocentesis and lavage to more complex open joint surgical
procedures. It is important to recognize that surgical treatment
rarely is performed alone; generally, it is supported by nonsurgical
treatment before and after surgery. Each surgical procedure should
have strict criteria for which cases are most appropriate. Recogniz-
ing that scientifically proven criteria are lacking, this article
discusses the suggested criteria for each procedure, ranging from
arthrocentesis to complex open joint surgery. The discussion in-
cludes indications, brief descriptions of techniques, outcomes, and
complications for each procedure.
Neuropathic Orofacial Pain: Proposed Mechanisms,

Diagnosis, and Treatment Considerations 209
Christopher J. Spencer and Henry A. Gremillion
The most common reason patients seek medical or dental care in
the United States is due to pain or dysfunction. The orofacial region
is plagued by a number of acute, chronic, and recurrent painful
maladies. Pain involving the teeth and the periodontium is the
most common presenting concern in dental practice. Non-odonto-
genic pain conditions also occur frequently. Recent scientific inves-
tigation has provided an explosion of knowledge regarding pain
mechanisms and pathways and an enhanced understanding of
the complexities of the many ramifications of the total pain experi-
ence. Therefore, it is mandatory for the dental professional to
develop the necessary clinical and scientific expertise on which
he/she may base diagnostic and management approaches. Opti-
mum management can be achieved only by determining an
accurate and complete diagnosis and identifying all of the factors
associated with the underlying pathosis on a case-specific basis.
A thorough understanding of the epidemiologic and etiologic
aspects of dental, musculoskeletal, neurovascular, and neuropathic
orofacial pain conditions is essential to the practice of evidence-
based dentistry/medicine.
Four Oral Motor Disorders: Bruxism, Dystonia,

Dyskinesia and Drug-Induced Dystonic
Extrapyramidal Reactions 225
Glenn T. Clark and Saravanan Ram
This article reviews four of the involuntary hyperkinetic motor
disorders that affect the orofacial region: bruxism, orofacial
dystonia, oromandibular dyskinesia, and medication-induced
extrapyramidal syndromedystonic reactions. It discusses and
contrasts the clinical features and management strategies for spon-
taneous, primary, and drug-induced motor disorders in the oro-
facial region. The article provides a list of medications that have
been reported to cause drug-related extrapyramidal motor activity,
and discusses briefly the genetic and traumatic events that are
associated with spontaneous dystonia. Finally, it presents an
viii CONTENTS
approach for management of the orofacial motor disorders. The
contraindications, side effects, and usual approach for medications
and injections are covered. An overview of the indications, con-
traindications, and complications of using botulinum toxin as a
therapeutic modality is discussed briefly.
A Critical Review of the Use of Botulinum Toxin

in Orofacial Pain Disorders 245
Glenn T. Clark, Alan Stiles, Larry Z. Lockerman,
and Sheldon G. Gross
This article reviews the appropriate use, cautions, and contraindi-
cation for botulinum neurotoxin (BoNT) and reviews the peer-
reviewed literature that describes its efficacy for treatment of
various chronic orofacial pain disorders. The literature has long
suggested that BoNT is of value for orofacial hyperactivity and
more recently for some orofacial pain disorders; however, the
results are not as promising for orofacial pain. The available data
from randomized, double-blind, placebo-controlled trials (RBCTs)
do not support the use of BoNT as a substantially better therapy
than what is being used already. The one exception is that BoNT
has reasonable RBCT data to support its use as a migraine prophy-
laxis therapy. The major caveat is that the use of BoNT in chronic
orofacial pain is off-label.
Complementary and Alternative Medicine for Persistent

Facial Pain 263
Cynthia D. Myers
This article discusses complementary and alternative medicine
(CAM), reviews literature on the prevalence of use of CAM by
the general adult population in the United States and by patients
with persistent facial pain, and summarizes published, peer-
reviewed reports of clinical trials assessing the effects of CAM
therapies for persistent facial pain. Results indicate that many
patients use CAM for musculoskeletal pain, including persistent
facial pain. Preliminary work on selected complementary therapies
such as biofeedback, relaxation, and acupuncture seems promising;
however, there are more unanswered than answered questions
about cost-effectiveness, efficacy, and mechanisms of action of
CAM for persistent facial pain.
Index 275
CONTENTS ix
Dent Clin N Am 51 (2007) 118
Overview of Orofacial Pain:

Epidemiology and Gender Dierences
in Orofacial Pain
Rene M. Shinal, PhDa, Roger B. Fillingim, PhDa,b,*
a
Department of Community Dentistry and Behavioral Science, College of Dentistry, University
of Florida, P.O. Box 103628 Gainesville, FL 32610-3628, USA
b
North Florida/South Georgia Veterans Health System, Malcolm Randall VA Medical
Center, 1601 SW Archer Road, Gainesville, FL 32608-1197, USA
Pain is the number one reason people seek health care; it is deemed the
fth vital sign, to mark its importance as health status indicator [1].
The most widely used denition of pain is an unpleasant sensory and
emotional experience associated with actual or potential tissue damage, or
described in terms of such damage [2]. Pain is a personal experience that
reects the totality of genetic, physiologic, and psychosocial contributions.
An area that is receiving considerable attention is the inuence of biologic
sex and gender role identity on the experience of pain. This article provides
an overview of current ndings regarding sex and gender dierences in clin-
ical and experimental pain responses, with particular attention to ndings
pertaining to orofacial pain. Evidence is presented from human and nonhu-
man animal studies that address sex dierences in pain sensitivity, pain tol-
erance, and analgesia. The potential mechanisms involved, as well as
implications for future research and clinical practice, are discussed.
Epidemiology of orofacial pain

Orofacial pain refers to a large group of disorders, including temporo-
mandibular disorders (TMDs), headaches, neuralgia, pain arising from
dental or mucosal origins, and idiopathic pain [3,4]. The classication and
epidemiology of orofacial pain presents challenges because of the many
anatomic structures involved, diverse causes, unpredictable pain referral
* Corresponding author. Department of Community Dentistry and Behavioral Science,

College of Dentistry, University of Florida, P.O. Box 103628 Gainesville, FL 32610-3628.
E-mail address: [email protected] (R.B. Fillingim).
2 SHINAL & FILLINGIM
patterns and presenting symptoms, and a lack of consensus regarding dier-

ential diagnostic criteria [5,6]. Despite these obstacles, several investigators
and professional associations have made progress in developing diagnostic
criteria [79]. For example, the International Association for the Study of
Pain and the International Headache Society have developed widely used
orofacial pain diagnostic criteria [10,11]. Similarly, Dworkin and LeResche
[12] have proposed Research Diagnostic Criteria for TMD, including a dual
axis system for classifying patients according to the predominant pain
source (eg, muscle pain, disk displacement, joint condition) and any associ-
ated psychosocial features (eg, disability, depression, somatization). The
often weak association between pain and observable tissue pathology has
prompted researchers and clinicians to use a multidimensional approach
for studying this widespread problem [13].
Chronic orofacial pain aects approximately 10% of adults and up to 50%
of the elderly [4]. There is evidence that sex dierences in masticatory muscle
pain and tenderness emerge as early as 19 years of age [14]. Women of repro-
ductive age, with a concentration of women in their 40s, seek treatment for
orofacial pain more frequently compared to men by a 2:1 ratio [1517]. More-
over, a greater proportion of women seek treatment for other pain con-
ditions, such as migraine and tension-type headaches, bromyalgia,
autoimmune rheumatic disorders, chronic fatigue, orthopedic problems,
and irritable bowel syndrome [16,18,19]. Women are more likely to seek med-
ical care for pain; however, they also report more pain for which they do not
seek treatment [20,21]. This holds true for all bodily symptoms, and for those
with unknown etiology [2224]. Women also experience more symptom re-
currences and more intense pain. These dierences persist when apparent
confounding factors, such as sex dierences in the prevalence rates of medical
conditions and gynecologic pain, are controlled statistically [22].
Kohlmann [17] noted that, among patients who presented with orofacial
pain lasting at least a week, more than 90% complained of pain in other
body areas as well. Patients who have orofacial pain share many similarities
with other patients who have chronic pain, such as a moderate correlation
between reported symptoms and objective pathologic ndings, maladaptive
behaviors (eg, parafunctions), social and psychologic distress, impairment of
daily activities, occupational disability, and higher rates of health care use
[16,25,26]. The result is a diminished quality of life that is constrained by
pain experiences.
Numerous factors with varying degrees of empiric support have been pos-
ited to explain sex dierences in pain prevalence. These include dierences in
descending central nervous system pathways that modulate pain signal trans-
mission [2729], genetics [30], and the eects of gonadal hormones [3134].
Also, a vast literature addresses psychosocial sex dierences in symptom ap-
praisal, socialization and gender roles, abuse and trauma, depression and
anxiety, gender bias in research and clinical practice, and race and ethnicity
[22,35].
EPIDEMIOLOGY & GENDER DIFFERENCES IN OROFACIAL PAIN 3
Sex dierences in responses to experimental pain

Although numerous factors inevitably contribute to sex dierences in the
prevalence and severity of clinical pain, the senior author and colleague [28]
previously suggested that sex dierences in the processing of pain-related
information could play an important role. That is, a higher level of pain
sensitivity among women may serve as a risk factor for developing certain
pain disorders, including chronic orofacial pain. A robust and expanding
literature that addresses sex dierences in experimental pain sensitivity
is available, and these ndings are discussed below.
Nonhuman animal research

Considerable research with nonhuman animals (primarily rodents) has
examined whether males and females dier regarding responses to noxious
stimuli [24,28,36] and analgesia [3739]. Rodent studies have yielded mixed
information concerning sex dierences in pain perception and analgesia
(called nociception and antinociception, respectively, when referring
to nonhuman animals). A comprehensive meta-analysis by Mogil and col-
leagues [39] found that female rats were more sensitive to electrical shock
and chemically-induced inammatory nociception (eg, abdominal constric-
tion, formalin tests) in most studies; however, results using thermal assays
were equivocal. Of the 23 studies reviewed, 17 reported no signicant sex
dierences; in the remainder, females exhibited more sensitivity to the hot
plate test than did males. With regard to radiant heat and hot water immer-
sion, most studies reported no sex dierences, with 8 reporting increased
sensitivity in male rats and 2 reporting increased sensitivity in female
mice. To clarify discrepancies, the investigators conducted additional noci-
ceptive testing and morphine antinociception experiments using a variety
of outbred mice and rats. Regarding nociception and morphine antinocicep-
tion, there was a signicant interaction between sex and genotype (ie, strain)
of rodents. To complicate matters, strain dierences can be relevant for one
sex, but not the other, and vary according to the pain assay. Female noci-
ception and antinociception also change across the estrous cycle; however,
when female mice were tested as a randomly mixed group (ie, estrous and
diestrus), sex dierences tended to diminish. The investigators noted that
males and females might use qualitatively distinct neurochemical mecha-
nisms to modulate nociception. They also suggested that the organizing ef-
fects of early hormone exposure during development might have more
impact than do adult gonadal hormone uctuations.
Human research
Laboratory pain research in humans suggests that women are more sen-
sitive to several forms of laboratory pain compared with men. Consistent
with rodent research, there is considerable variability in the magnitude
and direction of sex dierences [24,28,36]. A meta-analysis conducted by

Riley and colleagues [40] found that women generally show lower pain
thresholds and tolerances than do men to a variety of noxious laboratory
stimuli. Eect sizes for pain threshold and tolerance ranged from large to
moderate, and varied according to pain assay. Pressure pain and electrical
stimulation demonstrated the largest eects for the 22 studies reviewed,
whereas thermal pain yielded inconsistent results. The investigators con-
cluded that small sample sizes contributed to inadequate statistical power
and inconsistent results. Regarding cold pressor stimulation, studies show
that men generally display higher pain thresholds and tolerance, and lower
pain ratings than do women [41]; however, Logan & Gedney [42] noted a sig-
nicant sex-by-session interaction such that women anticipated and re-
ported more pain than did men after a second session of forehead cold
pressor testing. There were no sex dierences during the initial cold pressor
session, however. This indicates that previous experience with pain can af-
fect subsequent pain perception and modulation in a sex-dependent fashion.
Several studies have examined laboratory models of orofacial pain. For
example, Karibe and colleagues [43] noted that healthy female controls ex-
perienced more masticatory muscle pain during 6 minutes of gum chewing
than did men, and had more pain (compared with pretest measures) an
hour after chewing. Similarly, Plesh and colleagues [44] assessed jaw pain
tolerance in healthy subjects during and after bite force tasks. Both sexes
had increased pain during bite tasks; however, postclenching pain lasted
longer for women. Notably, women reported signicantly more baseline
pain upon jaw movement on the second day of testing, whereas men did
not report an increase in baseline pain 24 hours later. The investigators
ruled out muscular microtrauma because there were no signicant dier-
ences in postexertion pressure pain tolerance or threshold. Instead, they
suggested that neuronal hypersensitivity might play a role in postexertion
hyperalgesia.
Injection of algesic substances into the facial and cervical muscles also
has been used as an experimental model that mimics head and neck pain
of muscular origin [45]. Injections of hypertonic saline or glutamate solu-
tions into the trapezius muscle produced signicantly more pain among
women relative to men [46,47]. Similarly, pain induced by glutamate injec-
tions into the masseter muscle was more intense, larger in area, and longer
lasting in women [48]. Thus, sex dierences in pain perception extend to ex-
perimental models of particular relevance for clinical orofacial pain.
Another experimental pain model that may be of signicant clinical rel-
evance is temporal summation of pain. Temporal summation refers to a per-
ceived increase in pain that is generated by rapidly repeated noxious
stimulation [49]. This phenomenon is believed to be the perceptual correlate
that occurs when high-frequency stimulation of C-bers (C polymodal no-
ciceptive aerents) amplies second-order neuronal activity in the spinal
cord dorsal horn (ie, windup). This series of events involves N-methyl-D-
aspartate [NMDA] glutamate receptors [50,51]. Temporal summation is

thought to reect central neural mechanisms similar to those that are re-
sponsible for the hyperalgesia and allodynia that characterize many forms
of clinical pain [5157]. Healthy women exhibit more robust temporal sum-
mation than do men in response to thermal, electrical, and mechanical stim-
ulation [29,58,59]. Staud and colleagues [60] showed that patients who had
bromyalgia exhibited greater temporal summation of heat pain and height-
ened after-sensations compared with healthy controls. Similarly, patients
who had TMDs showed greater temporal summation of thermal and me-
chanical pain compared with pain-free controls [61,62]. Such ndings invite
speculation that individuals who display exaggerated temporal summation
of pain might be at greater risk for developing central sensitization of
pain pathways, which may reect a predisposition for developing chronic
pain syndromes [29]. There is a need for prospective longitudinal studies
to determine whether enhanced temporal summation of pain precedes
chronic pain, or is a consequence thereof.
Brain imaging studies

A rapidly expanding body of research uses functional brain imaging in an
attempt to identify cerebral responses that are associated with the experience
of pain [27,6366]. Several brain regions have emerged consistently as areas
that are activated during acute exposure to noxious stimuli. Acute painful
events often elicit activity in the primary and secondary somatosensory cor-
tices, insular cortex, anterior cingulate, and prefrontal cortices [27]. Bilateral
thalamic and brain stem activation have been associated with general
arousal (eg, attention) in response to noxious stimuli [65], whereas limbic
system components (eg, anterior cingulate, medial prefrontal, insular corti-
ces) are believed to reect emotional aspects of pain anticipation and
processing [27,65,67]. The periaqueductal gray, regions of the anterior cingu-
late, and the orbitofrontal cortex are implicated in endogenous pain modula-
tion [27].
A small body of evidence addresses sex dierences in brain activation
patterns in the contralateral insula, thalamus, and prefrontal cortex in re-
sponse to experimentally evoked pain. For example, in response to a painful
thermal stimulus, patterns of pain-related brain activation showed similarity
between the sexes; however, women showed greater activation in the contra-
lateral prefrontal cortex, contralateral insular and anterior cingulate cortex,
and cerebellar vermis compared with men [68]. In contrast, Derbyshire and
colleagues [69] reported greater heat painrelated activation among men
versus women in bilateral parietal cortex, and in contralateral primary
and secondary somatosensory, prefrontal, and insular cortices. Women
showed greater activation in ipsilateral perigenual cortex. This conicting
pattern of results likely reects dierences in stimulus characteristics. Specif-
ically, Paulson and colleagues [68] used an identical (50 C) contact heat
stimulus, which was rated as more painful by women, whereas Derbyshire

and colleagues [69] adjusted the intensity of their laser stimulus to be equally
painful across sexes.
Several studies have examined sex dierences in cerebral responses to
stimuli delivered to deep abdominal body tissues (ie, visceral stimulation).
Berman and colleagues [70] found that, compared with women who had
irritable bowel syndrome (IBS), men who had IBS showed greater bilateral
insular cortex activation to rectal pressure. These investigators subsequently
showed that rectal distention produces greater activation in ventromedial
prefrontal and right anterior cingulate cortex, and left amygdala among
women who had IBS, whereas men who had IBS showed greater activation
in right dorsolateral prefrontal cortex, insula, and periaqueductal gray [71].
In contrast, Hobson and colleagues [72] found no sex dierences in cortical
activity evoked from esophageal stimuli in healthy subjects.
Thus, these ndings involving somatic and visceral stimuli indicate sub-
stantial overlap in brain areas that are involved in acute pain processing be-
tween men and women. The variable sex dierences that have emerged
across studies likely depend upon the stimulus properties and population
characteristics.
Sex dierences in analgesic systems

Many organisms, including humans, possess natural pain control mech-
anisms (ie, endogenous systems). Nonhuman animal studies have revealed
sex dierences for at least one form of endogenous pain modulation:
stress-induced analgesia (SIA). In rodents, mildly stressful events (eg, brief
swims in tepid water) recruit endogenous opiate systems, whereas intensely
stressful events (eg, forced cold-water swims) recruit nonopioid systems (eg,
NMDA glutamate receptors) more heavily [24,73]. Given the same stressor,
female rodents usually have equal or less SIA than do males. Blocking opi-
oid or NMDA receptors reverses SIA in male and ovariectomized female
mice, but not in intact female mice. This suggests that the neurochemical
and hormonal mechanisms that support SIA might dier for female and
male animals [74,75].
Methods for investigating endogenous pain inhibition also are available
in humans. One frequently used method is assessment of diuse noxious in-
hibitory controls (DNIC). DNIC, or counterirritation, refers to the process
whereby one noxious stimulus inhibits the perception of a second painful
stimulus. This phenomenon is believed to reect descending inhibition of
pain signals [76,77]. DNIC is presumed to operate through activation of de-
scending supraspinal inhibitory pathways that are initiated by release of en-
dogenous opioids [7881]. Several studies have investigated sex dierences in
the ecacy of DNIC, with mixed results. France and Suchowiecki [82] re-
ported that ischemic arm pain produced equal reductions in the nociceptive
exion reex (NFR, a pain-related reex in the biceps femoris in response to
electrical stimulation of the lower extremity) activity in women and men,

which indicated no dierences in DNIC. Serrao and colleagues [29] recorded
the NFR and pain intensity for 36 healthy adults randomized to a baseline,
nonpainful control or a painful cold pressor DNIC condition. As expected,
women, on average, had lower NFR temporal summation thresholds than
did men. The cold pressor produced greater increases in the stimulus inten-
sity at which temporal summation elicited a reex in men compared with
women, which indicated greater DNIC among men. In contrast, Baad-Han-
sen and colleagues [83] found no sex dierences in the ability of an ice-water
DNIC to modulate intraoral pain that was induced by the application of
a topical irritant (ie, capsaicin) in healthy participants.
Responses to analgesic medication (ie, exogenous analgesia) also might
dier as a function of sex, although the ndings are far from consistent.
For example, clinical studies have indicated greater morphine analgesia
among women [84], among men [85], and others have reported no sex dier-
ences in morphine analgesia [86,87]. Consistent sex dierences have been re-
ported in the analgesic eects of mixed action opioids (eg, pentazocine,
butorphanol, nalbuphine), which produce analgesia, in part, by binding of
k-receptors [88]. This class of medications also has partial agonist action
at d-receptors and antagonist action at m-receptors, which complicates the
side eect prole [89]. Among patients who experienced postoperative
pain after third molar extraction, Gear and colleagues [89] demonstrated
that pentazocine and butorphanol produced greater and longer-lasting anal-
gesia among women versus men. Subsequently, these investigators found
that a 5-mg dose of nalbuphine had paradoxic antianalgesic eects on
men [90]. To obtain analgesia, men required higher doses (20 mg) than
did women (10 mg). This trend persisted when body weight was included
as a covariate. Men also had more pain by the end of the study protocol,
whereas women, on average, did not return to their baseline pain levels.
This study demonstrates that subtle sex dierences exist in response to
k-opioids.
Experimental pain models also have been used to explore sex dierences
in opioid analgesia. With an electrical pain assay, women have shown
greater analgesic potency but slower onset and oset of morphine analgesia
than did men [91], although these investigators failed to include a placebo
condition and subsequently observed no sex dierences in analgesic re-
sponses to morphine-6-glucuronide, an active metabolite of morphine [92].
Zacny [93] reported that m-opioid agonists (eg, morphine, meperidine, hy-
dromorphone) produced greater analgesic responses among women using
cold pressor pain, but no sex dierences in analgesia emerged for pressure
pain. The authors group [94] found no sex dierences in morphine analgesia
using pressure, heat, and ischemic pain. Regarding mixed action opioids,
Zacny and Beckman [95] reported that men experienced slightly, though
not signicantly, greater analgesia in response to butorphanol. The authors
and colleagues [96] reported no sex dierences in pentazocine analgesia;
however, the melanocortin-1-receptor genotype (MC1R) was associated

with pentazocine analgesia in a sex-dependent manner [30]. Specically,
women with two variant MC1R alleles, associated with red hair and fair
skin, reported signicantly greater analgesia with the k-opioid pentazocine
during thermal and ischemic pain testing compared with women with one
or no variant MC1R allele; MC1R genotype was not associated with anal-
gesic responses among men.
In summary, evidence from clinical and experimental pain models present
a mixed picture of sex dierences in response to opioids, and the presence of
sex dierences likely depends on multiple factors, including the specic opi-
oid agonist and dose used, the pain model tested, and the timing of postdrug
assessments. Moreover, human and nonhuman animal data suggests that
sex-by-genotype interactions may inuence the ndings of such studies.
Clinical relevance of experimental pain responses

It has not been determined whether common mechanisms underlie sex
dierences in the epidemiology of clinical pain and sensitivity to experimen-
tal pain; however, this possibility is supported by increasing evidence that
experimental pain sensitivity predicts clinical pain responses [97]. Indeed,
patients who have certain chronic pain disorders, such as TMD [56,61],
IBS [98], headache pain [99], and bromyalgia [57], exhibit increased sensi-
tivity to a variety of experimental pain stimuli. Moreover, some evidence
suggests that within populations that have chronic pain, greater experimen-
tal pain sensitivity is associated with greater severity of clinical symptoms
[100103].
Fillingim and colleagues [104] investigated the relationship between heat
pain tolerance and threshold in healthy adults, and reports of daily pain in
the month preceding pain testing. Consistent with previous studies, women
reported more pain sites (but not more pain episodes) and greater health
care use in the month preceding experimental testing. Women also displayed
increased sensitivity to thermal pain after adjusting for baseline sensitivities
in warmth detection. Women who reported higher levels of clinical pain dur-
ing the month preceding testing exhibited lower thermal pain thresholds and
tolerances than did those who reported less clinical pain; however, men
showed no signicant relationship between clinical and experimental pain.
Growing evidence also suggests that experimental pain sensitivity may
predict future pain severity and response to treatment. Indeed, several stud-
ies now indicate that laboratory pain sensitivity that is assessed presurgically
predicts severity of postsurgical pain [105107]. Also, pretreatment ischemic
pain tolerance predicted pain reductions following multidisciplinary treat-
ment among women, but not among men, who had chronic pain [101].
More recently, pretreatment heat pain thresholds predicted the eectiveness
of opioids for neuropathic pain [108]. Taken together, these ndings support
the clinical relevance of experimental pain assessment, which implies that
sex dierences in experimental pain sensitivity are related to sex dierences

in clinical pain.
Responses to nonpharmacologic treatment

Women and men may respond dierently to pharmacologic pain treat-
ment, but little is known about sex dierences in the eectiveness of non-
pharmacologic interventions for pain. In a study of orofacial pain, women
who had TMD showed signicant decreases in pain 2 years after multidisci-
plinary treatment, whereas pain reports among men who had TMD
remained unchanged [109]. In the experimental setting, a cognitive interven-
tion encouraging a sensory focus aimed at pain reduction signicantly atten-
uated pain intensity among men but not women [110]. Also, exercising on
a treadmill reduced cold pressor pain ratings in women but not men,
whereas playing video games decreased pain in men but not women [111].
In the clinical setting, conventional physical therapy was more eective
for men who had back pain, whereas intensive dynamic back exercises pro-
duced greater pain reduction among women [112]. In another study, women
who had back pain showed signicant improvements in health-related qual-
ity of life with cognitive behavioral treatment and the combination of cog-
nitive behavioral treatment plus physical therapy, whereas men showed no
benet [113]. Other recent ndings indicate similar treatment gains for
women and men following active rehabilitation for chronic low back pain
[114], and one study reported better outcomes from multidisciplinary treat-
ment among men [115]. Thus, these ndings are mixed, but, on balance, they
suggest greater treatment responses for women, especially when treatments
are multimodal.
Mechanisms underlying sex dierences in pain perception

Several mechanisms have been proposed to explain gender dierences, in-
cluding biologic factors, such as genetic and hormonal inuences as well
as sex dierences in endogenous pain modulation. In addition, psychoso-
cial processes have been suggested, including gender roles and other cogni-
tive/aective inuences. Before discussing these putative explanatory
mechanisms, it is worth noting that this distinction between psychosocial
and biologic contributions is articial, because psychosocial variables can
reect or alter the underlying biologic processes that are involved in the
modulation of pain. In addition, sex dierences in pain inevitably are driven
by multiple mechanisms; therefore, reductionistic attempts to identify the
reason for sex dierences likely will be unsuccessful.
Gonadal hormones may contribute to sex dierences in pain modulation
and opioid analgesia. Experimental pain perception varies across the men-
strual cycle in healthy women, with the greatest pain sensitivity occurring
perimenstrually [116]. The severity of some pain disorders uctuates with
the menstrual cycle [117119]. For example, in patients who have TMD,
peak pain occurs perimenstrually and at the time of ovulation [120]. It is hy-
pothesized that rapidly dropping estrogen levels may be associated with
heightened symptoms in this population. Hormone replacement therapy
also has been associated with an increased risk for developing TMDs
[121] and back pain [122,123], and women who were using exogenous hor-
mones reported more severe orofacial pain compared with women who were
not using hormones [124]. Furthermore, postmenopausal women who were
taking hormone replacement showed lower pain thresholds and tolerances
compared with women who were not taking hormone replacement and
men [125,126]. Thus, endogenous and exogenous hormonal events aect
clinical and experimental pain responses.
Psychosocial factors also contribute to sex dierences in responses to
pain. Psychologic distress is common among patients who have orofacial
pain [127]. Several studies indicate that psychologic factors play a larger
role when TMD pain is myogenic (as opposed to arthrogenic), perhaps be-
cause of more parafunctional behaviors in the former group [128130]. Re-
garding emotion, two dimensions seem to be especially important for pain
modulation: valencedwhether an emotion is positive or negative, and
arousaldhow intensely the emotion is experienced [131]. Although negative
and positive emotions can inuence pain, more research has addressed the
eect of negative emotions. For example, fear is a high-intensity negative
emotion that is associated with threat or perception of imminent harm.
The fear response is characterized by autonomic arousal and temporary
pain attenuation (ie, ght, ight, or freeze). Fear-based analgesia is not
studied readily in humans because of ethical considerations. In comparison,
anxiety is a lower-intensity negative emotion that often heightens pain sen-
sitivity [131]. Thus, an emotional stimulus can attenuate or amplify pain de-
pending upon how it is perceived.
Aggregate ndings suggest that, given the same negative stimuli (eg, up-
setting photographs, startling noise), women display more intense aective
reactions compared with men. In addition, women report higher base rates
of depression and anxiety than do men, which often are associated with in-
creased pain and other physical symptoms [132,133]. These negative aec-
tive states generally predict greater sensitivity pain in the laboratory [134].
Thus, higher levels of aective distress might account for some of the in-
creased pain sensitivity among women. Robinson and colleagues [135]
found that sex dierences in temporal summation of heat pain became non-
signicant after controlling for anxiety, indicating that anxiety mediates
gender dierences. Several studies suggest that anxiety more strongly
predicts experimental pain responses in men than in women, however
[136138]. Similar results have been reported for clinical pain [139]. Thus,
it seems that anxiety more strongly predicts clinical and experimental pain
among men. Clearly, more investigation is warranted concerning the role
of negative emotions during pain processing.
In addition to emotional factors, cognitive variables, such as self-ecacy,

anticipation, expectancies, perceived ability to control pain, and coping
strategies, can contribute to gender dierences in pain perception and treat-
ment outcomes [16,140]. Orofacial patients who have positive pretreatment
expectations, and who use adaptive cognitive coping strategies, report better
treatment satisfaction [141,142]. Relative to men, women report more worry
and catastrophizing in laboratory and clinical pain settings [143,144].
Turner and colleagues [145] found that a catastrophizing coping style was
associated with extraoral muscle and joint palpation pain, activity interfer-
ence, and higher health care use in patients who had TMDs. Despite
a greater tendency to catastrophize, Unruh and colleagues [146] found
that women use a broader repertoire of coping strategies. Furthermore,
men and women seem to derive dierential benets from coping skills train-
ing, which highlights the importance of tailoring treatments to meet individ-
ual needs [140].
Stereotypic gender roles also should be considered because traditional
Western feminine roles may enable reporting pain, whereas masculine roles
discourage such complaints. Among men, masculinity has been associated
with higher pain thresholds [147]. One study found that men reported less
pain to an attractive female experimenter than to a male experimenter,
whereas experimenter gender did not inuence womens pain reports
[148]. Two studies that used standardized measures of gender role demon-
strated that gender roles are associated with experimental pain responses,
but gender role measures did not account for sex dierences in pain
[147,149]. More recently, a subscale that assesses willingness to report
pain was found to mediate sex dierences partially in temporal summation
of heat pain [135]. Also, feminine gender role and threat appraisal mediated
sex dierences in cold pressor pain [140,150]. Thus, gender roles seem to
contribute to sex dierences in pain sensitivity.
Summary and future directions

Considerable clinical and experimental evidence demonstrates gender and
sex dierences in the epidemiology, etiology, and manifestation of orofacial
pain. Experimental studies in humans consistently indicate greater pain sen-
sitivity among women, although the magnitude of the sex dierence varies
across studies. Some evidence suggests sex dierences in responses to phar-
macologic and nonpharmacologic treatments for pain; however, conicting
ndings abound. The mechanisms that underlie these sex dierences in clin-
ical and experimental pain responses are not understood fully; however, sev-
eral biopsychosocial factors are believed to contribute, including gonadal
hormones, genetics, cognitive/aective processes, and stereotypic gender
roles.
A clinically relevant area for future research involves identifying sex-re-
lated markers that distinguish individuals who are at risk for developing
chronic pain from those who are comparatively resistant. The relative con-
tributions of genetic, anatomic, neurochemical, and hormonal factors re-
main unknown, although, they all seem to inuence the pain experience.
It also is important to consider that psychosocial factors exert powerful ef-
fects on pain modulation, and the neurobiology of these processes requires
further investigation. Most research has focused on the magnitude of sex
dierences in responses to pain and its treatment; however, a potentially
more important issue is identifying sex-specic determinants of pain and
treatment outcome. Because pain involves multifactorial and redundant sys-
tems, it is unlikely that a single medication or treatment will suit all patients
needs [151]. Thus, increased eorts to elucidate qualitative sex dierences
may be informative for developing new analgesic agents and multidimen-
sional therapeutic techniques. The advancement of knowledge regarding
sex, gender, and pain signies a promising step toward designing targeted
diagnostic techniques and treatment methods.
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Dent Clin N Am 51 (2007) 1944
Peripheral Mechanisms
of Odontogenic Pain
Michael A. Henry, DDS, PhD*,
Kenneth M. Hargreaves, DDS, PhD
Department of Endodontics,
University of Texas Health Science Center at San Antonio School of Dentistry,
Mail Code 7892, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
These are exciting times in the eld of pain research. Every day brings ad-
vances in our understanding of pain mechanisms, and with each new ad-
vancement there is hope that these ndings will lead to the development
of novel and more eective analgesics not only for acute pain, but also
for the more dicult and challenging to manage chronic pain conditions.
The eld of pain research represents an evolving eld, where early studies
identied basic pain pathways and the characterization of dierent ber
types and receptors that were activated by noxious stimuli. With this basic
knowledge, the receptors and transmitters involved in the activation and in-
hibition of these dierent pathways were identied, and signicant changes
in their expressions were seen after inammatory and nerve lesions. These
changes in receptors and transmitters were also correlated with the increased
activity of pain pathways in pathologic conditions. Advances in brain imag-
ing techniques have led to the concept of pain as a widely distributed system
involving many dierent nervous system structures that represent the aec-
tive and sensory aspects of the pain experience. Molecular approaches are
being used to map the intricacies of the intracellular signaling pathways
that are activated when molecules bind to a receptor or channels open in re-
sponse to specic stimuli. Genetic analyses allow comparisons in the make-
up and the identication of possible polymorphisms that might underlie
dierences in the way that individuals respond to painful stimuli and insults.
Pain researchers have the challenging task to consider this wealth of
This work was supported by NIH Grants DE013942 and DE015576 (M. Henry) and
DA016179 and DA19585 (K. Hargreaves).
* Corresponding author.
E-mail address: [email protected] (M.A. Henry).
20 HENRY & HARGREAVES
knowledge regarding pain mechanisms when designing experiments, and cli-

nicians who treat pain are anxiously waiting the time when these advances
will make their treatments more eective. In one respect, the activation of
the peripheral nociceptor and sensory neuron represents our rst key step
to our understanding of nociception. In this article, we review the key basic
mechanisms associated with this phenomena and more recently identied
mechanisms that are current areas of interest. Although many of these
pain mechanisms apply throughout the body, we attempt to describe these
mechanisms in the context of trigeminal pain.
Peripheral pain mechanisms associated with odontogenic or temporo-
mandibular disorders and other orofacial pain conditions are generally sim-
ilar to those seen elsewhere in the body. These similarities include the types
of sensory neurons involved and the receptors, channels, and intracellular
signaling pathways responsible for the transduction, modulation, and prop-
agation of peripheral stimuli. Even though there are some structural features
associated with the tooth pulp that make pulpal pain unique, the tooth pulp
is considered as a model system to illustrate peripheral pain mechanisms as-
sociated with the trigeminal system. This also seems appropriate because
toothache is a common presenting symptom for patients seeking dental
care [1]. The use of the tooth as a model system for studying pain mecha-
nisms is well established, and advantages include a rich representation of
pain bers [2] and that the stimulation of pulpal nerves produces mostly
a pain sensation [35]. In this regard, the tooth as a sensory organ can be
considered as a specialized receptor for nociception.
The tooth pulp is composed of connective tissue that is highly vascular
and rich in broblasts. Within this connective tissue stroma are bundles
of axons that provide innervation to the tooth pulp [6]. The distribution
and overall pattern of nerve bers within pulpal tissues have been studied
extensively, including in humans and experimental animals. The majority
of the axons enter the apex of the tooth, but others may enter accessory fo-
ramina when present and ascend the radicular pulp within ber bundles
composed of myelinated and unmyelinated nerve bers (Fig. 1). Nerve bers
located in these ber tracts ascend the pulp and terminate as free nerve end-
ings within the pulp or after entering the sub-odontoblastic plexus sequen-
tially along this path. The sub-odontoblastic plexus is located just inside
the odontoblasts and represents a ne network of many small and mostly
unmyelinated bers, many of which originate from thinly myelinated bers.
The sub-odontoblastic plexus (plexus of Raschkow) is extensive and espe-
cially elaborate in the region of pulp horns. The odontoblasts outline the en-
tire periphery of the dental pulp and are located at the pulpodentin junction.
Many of the unmyelinated nerve bers located in the subodontoblastic
plexus pass toward and terminate in the odontoblastic layer as free nerve
endings, whereas others terminate in the predentin or enter dentin by way
of dentinal tubules where they extend about 100 mm [7]. Although more
than 40% of dentinal tubules are innervated in the tip of pulp horns, far
PERIPHERAL MECHANISMS OF ODONTOGENIC PAIN 21
Fig. 1. Confocal micrographs of nerve bers in the human tooth as identied with the indirect
immunouorescence technique. (A) The coronal aspect of the pulp contains nerve bers as iden-
tied with the neuronal marker PGP9.5 (red) located within ber bundles (large arrow) and
small axons that traverse the odontoblastic layer (small arrow). Scale bar, 100 mm. (B) Nerve
bers located in the radicular pulp contain sodium channels (red) that are prominent at nodes
of Ranvier (arrow) as identied by the paranodal staining of caspr (green). Scale bar, 10 mm.
fewer tubules are innervated in more apical locations, with less than 1% of
tubules innervated in the midradicular region [8]. Stimulation of unmyelin-
ated nerve bers located in the pulp typically produces a dull throbbing and
poorly localized pain sensation, whereas stimulation of the dentin produces
a sharp, shooting pain that implicates the activation of more rapidly con-
ducting myelinated bers.
The nerve ber density within human teeth is quite impressive. A number
of ultrastructural studies have evaluated the type (as based on ber diameter
and presence or lack of myelin) and number of axons that innervate anterior
and posterior teeth. Comprehensive studies of nerve bers within posterior
teeth are limited to single-rooted premolars (reviewed in [9]). Nair [9] con-
cluded that human premolar teeth contain 2300 axons at the apex; 87%
of these are unmyelinated, and the remainder are myelinated. The vast ma-
jority of the myelinated bers are thinly myelinated and fall in the A-delta
class, and the remaining 7% represent the more thickly myelinated A-beta
nerve bers. Even though the average premolar tooth has a signicant
nerve density, this can vary depending on the developmental stage and
type of tooth [1012] and can vary widely among individual samples. The
innervation density is also dynamic because it can increase in human teeth
with caries [12]. Other axons that enter the tooth pulp originate from post-
ganglionic sympathetic neurons located in the superior cervical ganglion and
whose role involves vasoconstriction [13], whereas parasympathetic bers

may be lacking that provide a vasodilatory role elsewhere [14]. Pulpal vaso-
dilation can be achieved by the release of vasoactive neuropeptides from pri-
mary aerent terminals, a process that is integral to the production of
neurogenic inammation [15]. This process most likely involves arterioles
because these vessels are most densely innervated in the tooth pulp [16].
Studies in experimental animals have also described the innervation of
teeth, but, unlike in human studies, these studies allow a characterization
of the sensory neurons within the trigeminal ganglion that supplies the in-
nervation to pulpal tissues. Sensory neurons that supply the tooth pulp
have been identied after the retrograde transport of uorogold to exposed
dentin. These studies have found that pulpal aerents typically originate
from cell bodies with small, medium, and large diameters [17,18]. The cyto-
chemistry of sensory neurons in the spinal system has been extensively eval-
uated, and in general these studies have identied two broad classes of
neurons: (1) those that include peptidergic neurons that respond to nerve
growth factor (NGF) and that express the trkA receptor and peptides
such as calcitonin gene-related peptide (CGRP) and substance P (SP) and
(2) nonpeptidergic neurons that respond to glial cell linederived neurotro-
phic factor (GDNF) that express GDNF receptor alpha-1 and receptor ty-
rosine kinase (RET) and that bind the isolectin B4 (IB4). The IB4-binding
neurons usually also express P2X3, an ATP-gated ion channel. In compar-
ison, studies that have evaluated the cytochemical content of pulpal sensory
neurons show some important dierences when compared with the spinal
system. Most notable is the lack of IB4 binding [19,20]. Even though these
pulpal aerents do not express IB4 binding, they do express the P2X3 recep-
tor, which is also a marker of the nonpeptidergic class and is usually coex-
pressed with IB4 binding in the spinal system. A recent study has found that
many of the pulpal sensory neurons express the GDNF receptor alpha-1 and
that many of these coexpressed the trkA receptor [18]. Therefore, pulpal af-
ferent neurons express markers for peptidergic and nonpeptidergic neurons
within the same neurons and do not follow patterns typically seen in the spi-
nal system.
Many of the peptides and other molecules that have been identied as im-
portant in the activation of nociceptors in the spinal system have also been
identied in the trigeminal system. Some of the peptides identied in tooth
pulp include the tachykinins SP [21] and neurokinin A [22], vasoactive
intestinal peptide [23], neuropeptide Y (NPY) [24], methionine- and leucine-
enkephalin [25], CGRP [26], cholecystokinin and somatostatin [27], and gal-
anin [28]. Peptides as a group are important in nociception because the
expression of some change considerably with injury or after inammatory
insults. Sprouting of CGRP bers is seen in the rat tooth pulp after inam-
matory lesions [29], and similar results involving increased bers with
CGRP, NPY, SP, and vasoactive intestinal peptide have been described in
human teeth with carious lesions [30,31]. These same neuropeptides are
especially implicated in inammatory processes because sensory nerve stim-

ulation can lead to their local release by way of an axon-reex [32], or they
may be released from nerves that innervate blood vessels, leading to vasodi-
lation and protein extravasation, which results in a neurogenic inammation
[33]. Neurogenic inammation seems especially important in the trigeminal
system because it represents a basic mechanism associated with the patho-
physiology of migraine [34] and may be an important event associated
with the inammation of periodontal disease [35] and in the regulation of
the immune response to infection [36]. Neurogenic inammation and local
tissue injury are associated with the release or activation of many dierent
molecules that are involved in the sensitization of peripheral nociceptors, in-
cluding their ability to further enhance the release of CGRP and SP. These
substances include cytokines, NGF, prostaglandins, histamine, bradykinin,
ATP, serotonin, lipids, nitric oxide, and hydrogen ions. The local release of
CGRP and SP from peripheral terminals may bind to CGRP and SP recep-
tors on immune cells, and this binding may be involved in the regulation of
the immune response in a paracrine fashion. For example, SP released from
nerve terminals can bind to mast cells, leading to degranulation and the re-
lease of histamine [37]. The degranulation of mast cells also releases tryp-
tase, which is eective in the cleavage and activation of a new class of
protease-activated receptors (PARs) and especially the PAR-2 receptor.
PARs are colocalized with SP and CGRP receptors on nerve terminals
and when activated can result in the additional release of SP and CGRP,
thus perpetuating the inammatory response. The eects of most neuro-
peptides are mediated by receptor binding, and many of these are G-
proteincoupled receptors (GPCRs), which are discussed in greater detail
in this article. The local release of neuropeptides that occurs in inamed tis-
sues represents an important event leading to the sensitization of peripheral
nociceptors, and the specic mechanisms involved in this process will most
likely remain a focus of pain research in the future.
Based upon these considerations, peripheral terminals of nociceptors can
be envisioned as environmental detectors [38]. Although peripheral nocicep-
tors have a relatively simple morphology of free nerve endings (Fig. 1A),
they are biochemically specialized by the expression and localization of var-
ious receptors and ion channels, which confer to these cells the ability to de-
tect noxious chemical, thermal, and mechanical stimuli. These nociceptive
polymodal detectors can trigger this local release of neuropeptides (ie,
the axon reex), leading to coordinated inammatory and healing responses
in the injured tissue and evoking action potentials that provide sensory in-
formation back to the central nervous system (CNS).
From the perspectives of understanding peripheral pain mechanisms and
management, the following section reviews the major classes of receptors
and ion channels that confer the ability of nociceptors to detect noxious
changes in their peripheral area. Fig. 2 summarizes these major classes of re-
ceptors and ion channels. Understanding their pharmacology (Table 1)
Fig. 2. Cartoon depicting major classes of receptor or ion channels proposed to be present on
peripheral terminals of sensory neurons that serve to transduce external stimuli into altered neu-
ronal function. Not all receptors or ion channels are present on all neurons, and several have
been shown to be altered during inammation or nerve injury. PAR-2, protease-activated recep-
tor subtype 2; PG, prostaglandin; TRPA1, transient receptor potential A1; TRPM8, transient
receptor potential M8; TRPV1, transient receptor potential V1 (aka the capsaicin receptor);
VGCC, voltage-gated calcium channel; VGKC, voltage-gated potassium channel; VGSC, volt-
age-gated sodium channel.
provides insight into the pharmacologic strategies for peripheral pain con-
trol and permits appreciation of ongoing research designed to develop
new peripherally acting analgesics. For example, the demonstration that
dental pulp contains opioid receptors [39] and that peripherally adminis-
tered opioids reduces pain in endodontic patients [40] suggests that locally
active opioid analgesics might represent a novel class of drugs useful to treat
endodontic pain patients. Because peripherally active opioid analgesics are
under active development, it can be appreciated that a knowledge of periph-
eral pain mechanisms can improve our understanding of current and future
pain control strategies [41].
Mechanisms for detecting stimuli and clinical implications

G-proteincoupled receptors
The G-proteincoupled receptors (GPCRs) comprise a large superfamily
of receptors. The GPCRs share a common structure (seven transmembrane
regions on the protein) and are called G-proteincoupled because they
share a common signaling mechanism via activation of a certain class of
GTP-binding proteins (aka G-proteins). Thus, the GPCR undergoes a con-
formational change when a drug or endogenous substance binds to the re-
ceptor, resulting in the GPCR binding to a G-protein and initiating
a second messenger signaling pathway [42]. Although there are many sub-
types of G-proteins and second messenger systems, and the actual signaling
pathways are far more complicated than space permits, for our purposes we
focus on the three major subtypes of G-proteins: Gai/o, Gas, and Gaq and
their classic signaling pathways.
GPCRs that are coupled to the Gai/o signaling pathway include opioid,
cannabinoid, somatostatin, certain adrenergic subtypes, NPY, and GABA(B)
receptors. In general, activating a Gai signaling pathway leads to the inhibi-

tion of neuronal function by reducing cAMP levels, opening certain potassium
channels (leading to a more negative membrane potential, called hyperpolar-
ization, and thus reducing the probability of triggering an action potential)
and inhibiting certain calcium channels. As a rst approximation, drugs
that activate the Gai GPCRs that are expressed on nociceptors would be pre-
dicted to be peripherally active analgesics. Drugs that activate peripheral opi-
oid, cannabinoid, adrenergic, Y1, or GABA(B) receptors produce peripheral
analgesia or inhibit peripheral neuronal function [40,4345]. Clinicians use
several drugs that activate Gai GPCRs, and many additional drugs are in de-
velopment as analgesics that act by these mechanisms.
In many respects, the Gas GPCRs are complimentary to the Gai family
of GPCRs because these receptors typically increase cAMP levels, leading to
cellular excitation. Examples of GPCRs that are coupled to the Gas signal-
ing pathway include prostaglandins and CGRP (Table 1). Recent molecular
studies have demonstrated that of the four known subtypes of prostaglandin
receptor, only the EP2 and EP3 subtypes are expressed in trigeminal sensory
neurons [46]. Thus, local increases in prostaglandin E2 in dental pulp [47,48]
or periradicular exudates [49,50] are likely to contribute to odontogenic pain
mechanisms via activation of EP2 or EP3 receptors expressed on trigeminal
sensory neurons. Although EP receptor antagonists have been developed,
the current clinical strategy to control this receptor system is via the use
of nonsteroidal anti-inammatory drugs (NSAIDs) or via glucocorticoid
steroids. Both classes of drugs block prostaglandin synthesis by interfering
with the function of cyclooxygenase I/II (NSAIDs) or with phospholipase
A2 (steroids).
Several GPCRs are coupled to the Gaq signaling pathway, including bra-
dykinin, protease-activated receptors, endothelin, SP, and leukotriene recep-
tors. In general, activation of a Gaqcoupled GPCR leads to activation of
the phospholipase C/protein kinase C signaling pathways. This can evoke
a considerable stimulatory eect on nociceptors, leading to sensitization
of the capsaicin receptor, transient receptor potential V1(TRPV1). Recent
studies have demonstrated that activation of the phospholipase C signaling
pathway can reduce the normally high threshold for activating TRPV1 from
temperatures of w43 C to as low as w37 C [51]. This would lead to spon-
taneous activation of TRPV1 at body temperatures, possibly contributing to
the spontaneous pain in patients who have irreversible pulpitis or acute api-
cal periodontitis or other orofacial pain conditions. Prior studies have pro-
vided evidence for activation or functional activity of the bradykinin,
endothelin, SP, and leukotriene systems in dental pulp [5259].
Voltage-gated ion channels

Voltage-gated ion channels (VGICs) are transmembrane, pore-
forming proteins that allow the selective passage of certain ions in a
26
HENRY & HARGREAVES
Table 1
Examples of neuronal receptors, their ligands, and drugs that likely modulate odontogenic pain
Natural ligand In trigeminal
Receptor class Receptor subtype or stimulus Drug In dental pulp ganglia
Opioid Mu (MOR) b-endorphin Opiates [39,176]
Delta (DOR) Met-enkephalin None available
Kappa (KOR) Dynorphin (?) Pentazocine
Cannabinoid CB1 Anandamide None available [175]
CB2 ? None available [175]
Somatostatin Sst1-5 Somatostatin Octreotide [176]
Adrenergic Alpha (family) Norepinephrine Vasoconstrictors [44]
Beta (family) Epinephrine Albuterol, etc. [177]
GABA GABA (B) GABA Baclofen [178]
NPY Y1 (etc.) Neuropeptide Y None available
Prostaglandin EP2, EP3 (etc.) PGE2 NSAIDs, steroids [46]
CGRP CGRP-R1, -R2 CGRP CGRP28-37
Bradykinin B1 Kallidin Des-Tyr HOE140
B2 Bradykinin HOE140, steroids [179]
Protease (PAR) PAR2 (etc.) ?
Endothelin ETA, ETB Endothelin Atrasentan (antagonist) ?
Substance P NK1, NK2 Substance P L-703,606
Leukotriene BLT1, 2 and CysLT1, 2 LTB4, LTD4 Monteleukast, zarlukast [55]
VGSC Nav1.1 (etc.) Local anesthetics
VGCC ?
VGKC ?
TRP TRPV1 Heat, acid, some lipid-like Capsaicin
compounds
PERIPHERAL MECHANISMS OF ODONTOGENIC PAIN

TRPA1 Cold (?) Mustard oil, garlic
TRPM8. Cold Menthol
Trk trkA (etc.) ? [172]
Cytokine IL1-RI, IL1-RII IL1 Anakinra
TNF TNFa Adalimumab
Innate PAMPS Toll4 Endotoxin (LPS) [180]
CD14 Endotoxin (LPS) [180]
Presence in dental pulp as evaluated by anatomical, biochemical, or pharmacologic methods.
Abbreviation: PAMPS, pathogen-associated molecular patterns.
27
voltage-dependent manner. There are more than 140 members of this super-
family representing one of the largest collections of proteins involved in signal
transduction [60]. They also represent key therapeutic targets given their im-
portance in transduction. Within this superfamily are several important clas-
ses of ion channels that include the potassium (K), calcium (Ca2), and
sodium (Na) VGICs. The activation of these classic channels is a key process
involved in the initiation and propagation of action potentials and in the re-
lease of neurotransmitters involved in synaptic transmission. Their impor-
tance in pain pharmacology is recognized because analgesics exist that
function directly on the Na and Ca2 VGICs, and the actions of many dier-
ent drugs produce analgesia indirectly through eects on K channels.
There is a great deal of similarity in the structure of these dierent classic
VGICs, and this homology suggests a similar origin of not only these classic
channels but of the entire superfamily [61]. The K channels represent the
ones with the simplest structure, whereas the Ca2 and Na channels repre-
sent modications of this structural motif. The Na channel was the rst of
these to be described [62,63] and consists of an alpha subunit consisting of
four homologous domains (IIV) that surround a central pore for ion pas-
sage [64,65]. In addition to the pore, the alpha subunit contains a selectivity
lter that allows only certain types of ions to pass and a voltage-sensor that
allows a conformational change and opening of the pore based on voltage.
Each domain consists of six transmembrane a-helices referred to as S1
through S6. The structure of the Ca2 channel is similar to Na channels
[66], whereas the K channel consists of a tetramer of an identical protein
monomer that resembles one homologous domain of Na and K channels
[67]. Auxillary subunits are typically associated with the a-subunit, and, in
the case of Na channels, these beta subunits can modulate the expression,
localization, and gating properties of the a-subunits [68] and thus represent
possible therapeutic targets. Summary statements regarding the distribu-
tions, functional signicance, and possible therapeutic roles of each of the
channels included in the superfamily of voltage-gated ion channels have re-
cently been published. These statements include descriptions of the stan-
dardized nomenclature used to denote the dierent members of this class
[60].
Although it is dicult and most likely unfair to summarize the contribu-
tion of each of these classic VGICs in neuronal function, the following gen-
eralizations can be made. The activation of Na channels is critical for
action potential (nerve impulse) initiation and propagation. The opening
of the voltage-gated Na channels occurs when a transient generator poten-
tial is created by the activity of other ion channels (such as transient receptor
potential [TRP]), thus reaching the critical level needed to open the pore. If
enough Na ions enter the axon, a depolarizing threshold is reached, result-
ing in the initiation of an action potential. Thus, drugs that block sodium
channels (eg, lidocaine) play a critical role in dental therapeutics. The acti-
vation of the K channel is necessary to hyperpolarize (bringing the resting
potential within the nerve membrane back to a negative potential) and thus
terminating the action potential. Therefore, the activation of the classic volt-
age-gated Na channel initiates this activity, whereas the opening of K
channel results in the termination of nerve activity. The role of the volt-
age-gated Ca2 channels in nerve activity is more complex because calcium
entry into neurons can produce profound short- and long-lasting eects on
many dierent cellular functions due to its role as a second messenger and
involvement in intracellular signaling pathways. Important functions of
voltage-gated Ca2 channels include its inuence on cell body excitability
and the ability to gate the entry of calcium into nerve terminals, leading
to vesicle fusion and release of neurotransmitter during synaptic transmis-
sion. Each of these channels, and especially the various subtypes, represents
possible therapeutic targets to control the altered excitability of nociceptors.
Evidence for the role of each of these classic VGICs and related members in
pain conditions is discussed below.
Sodium channels: the Navs

Much recent interest has been focused on the contribution of altered volt-
age-gated sodium channel expression to pain states [6971]. The importance
of sodium channels on pain transmission is well known because the success-
ful practice of painless dentistry largely depends on the sodium channel
blocking eect of local anesthetics. Sodium channels are important in action
potential initiation and propagation in response to normal stimuli [72], but
they also seem to have a role in increased neuronal excitability and espe-
cially spontaneous and ectopic activity associated with inammatory and
neuropathic pain states. The association of altered sodium channel function
with basic neuropathic pain mechanisms is strengthened by the relative ef-
fectiveness of medications with a sodium channel blocking eect, such as
the anticonvulsant carbamazepine in the treatment of neuropathic pain con-
ditions and especially trigeminal neuralgia [73,74]. The tricyclic antidepres-
sants also represent a useful neuropathic pain medication, and some of their
eectiveness may be due to a sodium channelblocking eect [75].
Sodium channels are recognized as a diverse group consisting of at least
nine dierent subtypes, or isoforms, localized to nervous system tissues and
designated as Nav1.1 through 1.9 [76]. Although all nine show similarities in
structure and as a group show more similarity in function than the Ca2 and
K families, some important dierences exist. These include a dierential
nervous system distribution [76] and important dierences in expression af-
ter inammatory or axotomy insults [77]. The relative dierences in expres-
sions are important physiologically because each sodium channel has unique
gating properties [66] that can inuence action potential initiation. The
isoforms that are normally expressed in sensory neurons include the
Nav1.1, -1.2, -1.6, -1.7, -1.8, and -1.9 isoforms. The Nav1.1, -1.2, and -1.6
isoforms are also found in the CNS, whereas Nav1.3 is seen in the
developing nervous system [78]. The Nav1.6 isoform is the predominant so-
dium channel located at nodes of Ranvier throughout the nervous system
[79,80] and thus is critically linked to the saltatory conduction of action po-
tentials in myelinated bers. The Nav1.7, -1.8, and -1.9 isoforms are prefer-
entially expressed in the peripheral nervous system and seen in a subset of
nociceptors [8183]. Their peripheral nervous system location makes them
attractive targets for the development of pharmacologic agents because
such agents may lack the CNS side eects associated with many of the cur-
rent medications that block sodium channels, such as anticonvulsants.
Nerve injury models have implicated the Nav1.3, -1.7, -1.8, and -1.9 iso-
forms in the generation of neuropathic pain. Nerve injury models result in
an upregulation of the previously non-expressed Nav1.3 gene in DRG neu-
rons [84], in dorsal horn neurons [85], and in dorsal horn and thalamic neu-
rons after spinal cord injury [86]. Peripheral nerve injury is associated with
a downregulation or loss of Nav1.8 and Nav1.9 in the DRG but with fewer
changes of both isoforms at the site of injury [8789]. The Nav1.8 isoform
has also been implicated in nerve injury hyperalgesia [90,91], including an
upregulation in nearby uninjured c-bers [92]. Axotomy of the inferior alve-
olar nerve also decreases Nav1.8 mRNA in trigeminal ganglion neurons, like
most studies done in the spinal system [93]. Recent human studies have also
found increased Nav1.7, -1.8, and -1.9 immunoreactivity and protein in in-
jured nerves, an association of increased Nav1.8 with hyperalgesia, and de-
creased expression in the injured DRG neurons [9497]. Primary
erythermalgia, a disease characterized by sporadic attacks of swollen, red,
and warm extremities, has recently been dened as a neuropathic pain dis-
order due to mutations in the SCN9A gene that encodes for the Nav1.7 pro-
tein [98]. Other recent ndings show no change in neuropathic pain behavior
in rats treated with Nav1.3 antisense oligonucleotides [99] and in knockout
mice lacking Nav1.7 and -1.8 [100], whereas a specic blocker of Nav1.7 and
-1.8 [101] and Nav1.8 [102] inhibited neuropathic behaviors. The role of al-
tered sodium channel expression in neuropathic pain states remains an ac-
tive area of research. The recent development of isoform-specic blockers
is encouraging, and the development of other specic blockers should help
to dene the role of altered isoform expression to the development of neu-
ropathic pain states.
Other studies have evaluated the eect of inammation on specic iso-
form expression, and these results have suggested the involvement of
Nav1.7 and the tetrodotoxin-resistant isoforms Nav1.8 and -1.9 in inamma-
tory pain mechanisms [103109]. The expression of these isoforms may be
mediated through prostaglandin signaling [110,111], and pretreatment
with ibuprofen can prevent the augmentation of Nav1.7 and -1.8 seen after
injection of complete Freuds adjuvant [112]. Nerve growth factor is also in-
volved in the expression of Nav1.7 [113] and Nav1.8 [114]. There is interest in
studying sodium channel expression in human dental pulp [115], and recent
studies have shown an increase in Nav1.8 in painful tooth pulp when
compared with normal tooth pulp [116,117]. One possible consequence of an

increased expression is a higher incidence of local anesthesia failures en-
countered when treating painful teeth [118]. Although dierences in the ex-
pression of the various isoforms are seen after nerve injury and
inammatory insults, the isoform that contributes most to the development
of altered neuronal excitability is unknown.
Potassium channels: the voltage-gated potassium channels and others

The potassium-selective channels represent the largest class of ion channels
and consist of diverse subtypes. The voltage-gated potassium (Kv) channels
are one subtype and represent about 40 of the 70 known potassium-selective
channels. Other Kselective channels include the inward rectifying, two-
pore, and Ca2activated K channels. The Ca2activated K channels in-
clude the big, intermediate, and small conductance K channels.
Each of the Kv genes encodes a single peptide subunit. The active Kv chan-
nel is composed of four subunits that can be homotetramers of the same sub-
unit or heterotetramers composed of various subunits from within the family.
The Kv family members, as designated with the IUPHAR [119] nomenclature
and followed by the HUGO Gene Nomenclature Committee nomenclature in
parentheses, include Kv1.11.8 (KCNA17, 10), Kv2.12.2 (KCNB12),
Kv3.13.4 (KCNC14), Kv4.14.3 (KCND13), Kv5.1 (KCNF1), Kv6.16.4
(KCNG14), Kv7.17.5 (KCNQ15), Kv8.18.2 (KCNV12), Kv9.19.3
(KCNS13), Kv10.110.2 (KCNH12), Kv11.111.3 (KCNH2,6,7), and
Kv12.112.3 (KCNH8,3,4). The Kv7 family represents the most interesting
family from a pharmacologic aspect because mutations in four of the subunits
have been associated with diseases such as long QT syndrome, deafness, and
seizures. The Kv7.2 to 7.5 subtypes are considered possible targets for the de-
velopment of anticonvulsants, and, due to the eectiveness of other anticon-
vulsants in neuropathic pain management, they may also represent
pharmacologic targets for pain management. This association seems to hold
true because the anticonvulsant retigabine (an opener of the Kv7.27.5 sub-
types) seems eective in some models of neuropathic and chronic pain [120].
Other Kv subtypes that may be implicated in pain include Kv1.4, which is
found in small-diameter dorsal root ganglion neurons [121], and the Kv4.2
subtype, which is localized to dorsal horn neurons and when inactivated by ex-
tracellular signal-related kinase after injury is inactivated and no longer able to
inhibit neuronal ring [122].
Other K channels that are implicated in pain mechanisms include
two members of the inward rectifying family, the KATP subtype and the
G-protein regulated inward rectier K channels (GIRK or Kir3). The
KATP subtype is implicated in peripheral analgesia because peripheral injec-
tions of the specic blockers pinacidil and diazoxide produced antinocicep-
tion in a paw pressure test [123]. The opening of KATP and GIRK channels
seems to be a critical step in the antinociceptive eects of many analgesic
medications, including opioids. This occurs indirectly because opioid bind-

ing activates Gi/o proteins, which open the KATP, GIRK1, and GIRK2
subtype K channels, thus contributing to antinociception [124,125]. Opioid
receptors located spinally primarily aect GIRK1 and GIRK2 [126],
whereas peripheral opioid analgesia primarily aects the KATP K channels
[127]. The activation of GPCRs by non-opioid agonists and the subsequent
opening of K channels underlie the analgesic action of many dierent med-
ications, including adrenoceptors, adenosine, 5-HT1A receptor agonists,
muscarinic and dopamine receptors, cannabinoid receptors, GABAB recep-
tors, some NSAIDs, tricyclic antidepressants, antihistamines, and gabapen-
tin [120]. Evidence suggests the involvement of the big and small
conductance K channel subtypes of the Ca2activated K channel family
in some of these eects. In summary, the activation and subsequent opening
of a number of dierent K channels seems to be a promising area of re-
search that may lead to the development of new classes of analgesics
through a direct opening eect on K channels or indirectly through the ac-
tivation of GPCRs.
Calcium channels: the voltage-gated Ca2 channels and a few others

Activation of the voltage-gated Ca2 (Cav) channels have broad-reaching
eect on cellular function due to the role of calcium as an important intra-
cellular second messenger system in addition to critical roles in the control
of neuronal excitability and the release of neurotransmitters. The structure
of the Cav is similar to that of the Nav, consisting of four homologous do-
mains with each domain consisting of a six-transmembrane a-helix segment
[128,129]. The a1 subunit may also be associated with b and a2-d and -g
subunits, which modify the gating characteristics of the a1 subunit. Currents
due to calcium channel activation were initially characterized based on their
physiologic properties (L, N P/Q, and R) and then by an alphabetical
nomenclature based on that used to classify the Kv [129]. This classication
includes Cav1.1 through Cav1.4 (L current), Cav2.1 (P/Q current), Cav2.2
(N current), Cav2.3 (R current), and Cav3.1 through Cav3.3 (T current).
The Cav2 (P/Q, N, and R currents) channels are of great interest with re-
gard to pain mechanisms [130] because they are blocked by peptides isolated
from the venom of spiders and snails [131]. Ziconotide represents a new in-
trathecally administered analgesic that is approved for chronic pain resistant
to other therapies and that specically blocks activity at the Cav2.2 channel
and its N current [132]. It is a synthetic peptide based on the venom from the
marine snail Conus magus and inhibits the release of excitatory amino acids
from primary aerent terminals [133]. Inhibition of the N current is also
achieved with the opioid receptor like receptor 1 agonist, nociceptin, which
triggers a PKC-dependent internalization of N-type channels [134]. Mice
lacking the Cav2.2 channel show decreased inammatory and neuropathic
pain behaviors [135], suggesting important inuences of this channel on
the neurotransmission of nociceptive stimuli. The analgesic action of various

venoms may not be limited to the Cav2.2 channel because the venom from
the spider Phoneutria nigriventer inhibits all three currents associated with
the Cav2 channels [136]. The Cav3.2, T-type channel also represents a target
because antisense knockdown of this gene inhibits pain behaviors in a neu-
ropathic pain model [137]. Other potential targets related to the Cav include
the b3 [138] and the a2-d type 1 [139] subunits. Pregabalin is another new
medication that is related to gabapentin. Pregabalin is approved to treat
postherpetic neuralgia and diabetic neuropathy pain, and its analgesic ac-
tion may include its ability to bind to the a2-d type 1 subunit [140]. The
modication of Ca2 currents by drugs and venoms has led to the develop-
ment of new analgesics, and hopefully more medications with specic action
and fewer side-eects will be developed in this class.
The transient receptor potential channels

The TRP channels represent a family of six dierent members including
some that that act broadly in the transduction of sensory stimuli related to
pain, temperature, vision, hearing, taste, and pheromone detection [141].
Most are weakly gated by voltage and as a class act as nonselective cation
channels that allow the passage of Na, sometimes Mg2, and especially
Ca2 into cells. Because Ca2 plays an important role as an intracellular sec-
ond messenger, they are implicated in the control of many cellular processes,
including exocytosis, contraction, apoptosis, migration, cell development,
and neuronal excitability. They often work in concert with other receptors,
including GCPRs and tyrosine kinases. Tyrosine kinase activates phospho-
lipase C, leading to Ca2 release from the endoplasmic reticulum [142]. The
TRP family is somewhat related in structure to the K channels and consists
of six transmembrane loops. They can form homomeric functional units or
can form associations with other members, allowing the formation of het-
eromeric units. The six subfamilies of the TRPs include the vanilloid recep-
tor TRPs (TRPVs), the melastatin or long TRPs (TRPMs), the ankyrin
transmembrane protein 1 (ANKTM1 or TRPA1), the classic TRPs, the mu-
colipins, and the polycystins [143]. Four individual members within these
subfamilies (TRPV1, TRPV2, TRPM8, and TRPA1) have been strongly im-
plicated in pain signaling or some aspects of thermoreception, and all allow
the passage of Ca2 preferentially more than other cations.
The TRPV subfamily consists of six dierent members (TRPV16);
TRPV1 is the most intensely studied and best understood member of this
group [144,145]. The TRPV1 receptor was the rst molecule to be found
that is gated by temperature (R 43 C) and that represents the capsaicin re-
ceptor and was rst described as the vanilloid receptor (VR1). It is primarily
a Ca2permeable channel that is also gated by hydrogen ions and polyun-
saturated fatty acids and represents a possible receptor for the endogenous
cannabinoid anandamide [146]. TRPV1 knockout mice have shown that the
expression of this ligand-gated channel is critical for the development of

inammatory hyperalgesia [147,148] but is not necessary for the detection
of heat in normal (uninamed) tissues [149]. Capsaicin produces a neuro-
genic inammation (by evoking peripheral neuropeptide release) and pri-
mary and secondary hyperalgesia [150] and highlights the importance of
this receptor in this process. The receptor can be sensitized by inammatory
mediators such as bradykinin, prostaglandins, serotonin, ATP, and adeno-
sine [151]. This sensitization can lead to a potentiation of currents through
the channel and can result in lowering the temperatures needed to activate
the channel [152]. The TRPV1 channel also shows the ability to become de-
sensitized after prolonged stimulation. The TRPV1 channel represents an
attractive pharmacologic target because it is widely expressed in the trigem-
inal and dorsal root ganglion in small-diameter cell bodies that typically give
rise to unmyelinated axons, consistent with a nociceptive phenotype [153].
The TRPV1 receptor is seen in nociceptive tissues such as the human tooth
pulp [116], is found in peptidergic and nonpeptidergic sensory neurons
[154,155], and may play a role in neuropathic pain mechanisms [156]. Given
the importance that TRPV1 plays in inammatory pain mechanisms, it is
widely regarded as a phenotypic marker for nociceptive neurons.
The TRPV2 receptor is another member of the TRPV subfamily and may
play a role in the detection of noxious heat [157]. It is activated by higher
temperatures, with a threshold of 52 C, and is not activated by protons
or the vanilloids. The TRPV2 receptor is seen in larger cell bodies within
sensory ganglia, A-delta and A-beta myelinated bers, and in dierent cells
than TRPV1 [158]. More recently, the heat receptor story has been compli-
cated by the nding that TRPV1 and TRPV2 knockout mice respond nor-
mally to heat responses [149]. This surprising nding has led to their
hypotheses that under normal conditions there is a population of IB4-neg-
ative neurons that respond to heat in ways that do not involve TRPV1
and TRPV2 and that TRPV1 is active only after injury or in disease states.
Even though TRPV1 and TRPV2 have been implicated in the processing of
noxious heat stimuli, additional studies are needed to more fully describe the
role of each in this response.
The TRPM8 receptor was rst called the cold menthol-receptor 1 because
it binds menthol, thus producing its cooling eect [159,160]. Activity is in-
creasingly activated by cool and noxious cold temperatures that range
from 28 to 8 C and by other cooling compounds, such as icilin [161]. The
activation by menthol is important because this compound can initiate
a painful response when applied to human skin [162], leading to cold allo-
dynia but without the development of an axon reex [163]. Menthol can
also produce a sensitization of the receptor, leading to an increase in the
temperature, which is needed to activate the channel. TRPM8 has been
identied in primary aerent neuronal cell bodies that give rise to myelin-
ated A-bers and unmyelinated C-bers and has been seen in a dierent sub-
set of neurons than TRPV1 [153]. This study also classied the dierent
TRP receptors based on their associations with trk receptors and found an
important correlation of TRPM8 with the high-anity nerve growth factor
receptor trkA, which is seen as a marker of neurons that are critically in-
volved in inammatory pain mechanisms [164]. These studies have identied
the TRPM8 receptor as a cold receptor.
The TRPA1 receptor (rst called ANKTM1) was initially identied as
a cold receptor [165]. It is activated by temperatures below 17 C, but con-
icting evidence exists regarding its role in the signaling of noxious cold
[166168]. This receptor is activated by dierent naturally occurring com-
pounds (eg, allyl isothiocyanates, such as mustard oil and wasabi; thiosul-
nate allicin, which is found in garlic; and cinnamon) that, when applied to
skin, can produce pain and neurogenic inammation. Activation of
TRPA1 also mediates the inammatory response to environmental irritants,
such as tear gas and car exhaust [166], bradykinin [167], and some of the ef-
fects of peripherally administered cannabinoids [169]. This receptor may
also be involved in the detection of mechanical stimuli [167], an ability
that may be related to the presence of multiple ankyrin repeats also seen
in the TRPN1 receptor that mediates mechanotransduction in ies [170].
The TRPA1 receptor is found mainly in a subset of unmyelinated nocicep-
tors and is colocalized in a subpopulation of TRPV1 neurons [153]. Due to
its role in inammation, activation by many dierent compounds that pro-
duce pain when applied topically, and its colocalization with TRPV1, it rep-
resents an important receptor involved in the transduction and modulation
of painful stimuli.
In summary, the TRPs represent an important class of receptors involved
in the pain associated with peripheral inammation. The activation of some
of these receptors by thermal stimuli in pathologic conditions represents an
important nding. Given the ability of thermal stimuli and especially cold in
the production of a painful response in inamed teeth, the evaluation of
these receptors in pulp from normal and painful human extracted teeth
could provide additional insights into thermally mediated pain mechanisms.
Several other receptor systems are expressed on nociceptors and modu-
late the activity of this important class of sensory neurons (Table 1). The
neurotrophin receptors trkA, trkB, and trkC are expressed on sensory neu-
rons and detect tissue levels of NGF, BDNF, and GDNF, respectively. Of
particular interest to dentists, NGF has been shown to increase during
pulpal inammation [171,172], to sensitize TRPV1 [173], and to evoke hy-
peralgesia after injection in human volunteers [174]. Inammation likely in-
creases more than one neurotrophin, and these potent mediators
signicantly alter sprouting of trigeminal neurons [175].
The future: toward a molecular model of pain diagnosis and management

The last few decades have seen a tremendous change in the pain eld. Al-
though the gate control theory of the 1960s emphasized the importance of
dierences in patterns of aerent input as pivotal in pain perception, con-

temporary research has focused extensive eort toward understanding the
role of receptors and ion channels in the detection of noxious stimuli and
in the transmission and processing of this information. Because this article
focuses on peripheral mechanisms of odontogenic pain, we have discussed
those receptors and ion channels located in terminals innervating dental
pulp. This information has two major applications. First, a better under-
standing of peripheral pain mechanisms contributes to strategies for dental
pain control using currently available drugs and the next generation of an-
algesics. Equally important, knowledge of peripheral pain mechanisms is
likely to contribute to our understanding of many chronic pain conditions
and supports the development of hypothesis-driven translational clinical re-
search that is likely to increase our understanding of the pathophysiology of
many forms of acute and chronic pain.
Although we have focused on the detection of peripheral noxious stimuli
and its transmission, it would be overly simplistic to conclude that this is the
only important component in pain perception. For example, knowledge of
central pain mechanisms, including central sensitization, is equally impor-
tant in understanding and managing clinical pain conditions. In addition,
understanding the aective component of pain and its modulation by psy-
chosocial issues plays an important role in pain control, particularly in
chronic pain conditions. Todays skilled clinician must diagnose and treat
pain conditions based not on anecdotal lore but on a rm understanding
of the biology of pain conditions, the pharmacology of traditional and non-
traditional analgesics, and the outcomes from evidence-based clinical trials.
Our patients deserve no less.
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Dent Clin N Am 51 (2007) 4559
Central Mechanisms of Orofacial Pain

Robert L. Merrill, DDS, MS
Graduate Orofacial Pain Program, UCLA School of Dentistry,
13-089C CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095-1668, USA
A review of the literature for temporomandibular disorders (TMD) has

shown little appreciation for basic pain science, but with the expansion of
the perspective into the broader context of orofacial pain, there is a develop-
ing interest in understanding the pathophysiology of pain as it relates to
TMD and orofacial pain. The possibility of TMD being associated with
neuropathic pain has received little attention.
The International Association for the Study of Pain has dened pain as
an unpleasant, sensory and emotional experience associated with actual
or potential tissue damage, or described in terms of such damage. This
denition includes not only the sensory aspect of pain but also the emotional
and interpretive or cognitive aspects of pain. The emotional factors are more
signicant in chronic than in acute pain and assert a signicant inuence
that usually has to be recognized and addressed to eectively treat the
patient who has chronic pain. Often, chronic pain treatment failures can
be traced to ignoring the psychologic issues that are aecting the patients
pain condition.
The understanding of chronic pain has advanced signicantly in the last
10 years. This understanding has led to improved diagnosis and treatment
strategies for pain. Until recently, patients who had facial pain that did
not t the existing understanding and taxonomy were given the diagnosis
of atypical facial pain. The recent IHS Classication of Headache
provides a comprehensive classication system for head and neck pain
and has removed the atypical facial pain diagnosis in favor of persistent
idiopathic facial pain. This is an important step in disengaging the less un-
derstood facial pain condition from a co-psychosomatic diagnosis that was
implied in atypical facial pain [23].
To be able to diagnose and treat orofacial pain, one must understand
basic neurophysiology of pain from the periphery to the central nervous
46 MERRILL
system (CNS). This article describes the basis of central sensitization as it

relates to orofacial pain.
Pain transmission from periphery to central nervous system

Aerent sensory system: C-polymodal nociceptors and A-d
and A-b bers
A basic understanding of the peripheral and CNS is necessary to under-
stand pain mechanisms and to understand how central sensitization develops.
Most text books on pain discuss dorsal horn mechanisms when referring to the
CNS. For orofacial pain, the trigeminal correlate of the dorsal horn is the tri-
geminal nucleus within the pontine brain stem. Peripherally, the trigeminal
nerve provides sensory input from the anterior part of the head, including
the intraoral structures. Because the nociceptive endings of pain bers lack
specialized receptors, they are named from their aerent ber and the stimulus
that activates them. The sensory bers are divided into A-b mechanoreceptors
and three types of nociceptors: A-d bers, Cpolymodal nociceptors
(C-PMNs), and silent or sleeping nociceptors, which are unmyelinated or
thinly myelinated. The A-b bers that respond to light-touch mechanostimu-
lation are large diameter, fast conducting, and myelinated. No matter what the
frequency or intensity of the stimulus, these bers normally encode only low-
frequency, non-noxious stimuli that are interpreted as light touch [36]. After
trauma, the A-b bers may begin to signal pain. The A-d bers respond to
painful mechanical stimuli with an output in the high-frequency range. This
is perceived as sharp or stabbing pain. Because the A-d bers are myelinated,
the convey impulses more rapidly than the C-PMNs (Fig. 1) [79]. The silent
nociceptors are normally mechanically insensitive. They become active when
tissue is injured. These bers add to the nociceptive input to the CNS
[18,26,27]. The aerent impulses from all the sensory bers travel from the pe-
riphery through the trigeminal ganglion and trigeminal root, enter the pons,
and descend in the trigeminal tract to enter the trigeminal nucleus. Once the
bers have entered the pons, they are in the CNS.
The trigeminal nerve innervates the anterior of the head. These bers
travel to the trigeminal ganglion and to the trigeminal nucleus in the
pons. The trigeminal nucleus is subdivided into three parts: the uppermost
subnucleus oralis, the middle subnucleus interpolaris, and the subnucleus
caudalis (Fig. 2) [24]. Most of the pain bers synapse in the subnucleus cau-
dalis. For pain, the wide dynamic range neurons (WDRs) are the most im-
portant second-order neurons in the subnucleus caudalis. They receive
convergent sensory input from primary aerent nociceptors and low-
threshold mechanoreceptors.
Certain features of pain have long puzzled clinicians and researchers. The
stimulation of pain from a normally nonpainful stimulus has deed explana-
tion. Conversely, Beecher [1] puzzled over a battleeld phenomenon he
CENTRAL MECHANISMS OF OROFACIAL PAIN 47
Fig. 1. Aerent and eerent bers. This gure shows diagrammatically the make up of a typical
bundle of aerent sensory nerves going from periphery to the central nervous system. The
eerent sympathetic nerves follow a separate route from the central nervous system but even-
tually innervate the peripheral area in close proximity to the aerent sensory bers. The
large-diameter Ab bers are mechanoreceptors that respond only to non-noxious mechano-
stimulation. The Ad and C bers carry noxious stimulation. Figure suggested by Fields [7]
and altered for the trigeminal system. (Adapted from Fields HL. Pain. New York: McGraw-
Hill Book Company; 1987. p. 14.)
noted during the Second World War on Enzio Beach in Italy. Beecher
attracted attention to the role of cognitive appraisal with his observations
that soldiers wounded during battle complain far less than civilians compa-
rably injured during accidents, presumably because the soldiers were
Fig. 2. The trigeminal nucleus caudalis has been outlined in the medullary dorsal horn. Note
the lateral position of the nucleus and the somatotopic arrangement, which is similar to the spi-
nal cord dorsal horn Rexed laminar arrangement. Nociceptor axons descend in the trigeminal
tract and cross into lamina I/II or substantia gelatinosa at the level of the subnucleus caudalis.
The A-b bers synapse in lamina IV and V.
48 MERRILL
relieved that they had escaped from the battleeld and expected to return
home, whereas the civilians evaluated the injury as a threat to comfortable,
established lives. Contrasting ndings have shown that people who cata-
strophize or self-alarm by focusing negatively upon their distress suer
higher levels of anxiety and are the most disabled and benet the least
from conventional medical care [14,21]. Patients who have chronic low
back pain and are depressed have also been found to misinterpret or distort
the nature and signicance of their pain. These observations highlight the
presence of pain-modulating systems in the body that can turn down or
turn up the volume control for pain. This had been implied by Melzack
and Wall [20] but was poorly understood when they proposed the Gate Con-
trol Theory in 1965.
Second-order neurons
The rst interface between the peripheral nociceptors and the CNS occurs
in the spinal cord or trigeminal nucleus, the brainstem extension of the spi-
nal cord dorsal horn (see Fig. 2). There are many types of receptors and ion
channels associated with the cell membrane of the WDR that modulate cell
activity. Modulatory circuits can suppress WDR activity and decrease pain
or facilitate pain transmission.
The Gate Control Theory and pain modulation

Fig. 3 shows the Gate Control of Pain that was proposed by Melzack and
Wall in 1962 [20] and republished in 1965. Although there have been some
modications to the original theory, most of the system features have been
conrmed by research.
The Melzack and Wall model describes modulation of pain transmission
through the interneuron connections in the substantia gelatinosa. Past re-
search had identied a pain-modulating eect of aerent activity from
large-diameter A-b bers. The gate control model identied the spinal
cord substantia gelatinosa as one of the areas where pain is modulated.
Fig. 3 illustrates the modulating eect of the L (light touch bers) in reduc-
ing the eect of aerent activity from the S (c-nociceptors) bers. Melzack
and Wall [20] also theorized that there were descending inhibitory and facil-
itatory inuences, but little was known of these mechanisms in 1965, and it
has only been within the last few years that descending inhibitory and facil-
itatory systems have been identied.
Central pain processing and central sensitization

The phenomenon of peripheral sensitization develops from an injury-
induced inammatory response. Allodynia and hyperalgesia in this model
are due to the inammatory mediators being released at the site of injury.
Gate Control Theory of Pain

Central
Control
Gate Control System
L - +
+
Action
Input SG T
System
_
+
S -
Fig. 3. Melzack and Walls Gate Control of pain proposed that light-touch myelinated mecha-
noreceptors (L) modulated or decreased the gain of the small-diameter unmyelinated pain bers
(S) in the substantia gelatinosa or dorsal horn lamina II through the intermediary eect of seg-
mental interneurons in that lamina (SG). The action potential synapsed with the second-order
wide dynamic range neurons (T) to bring about the response to the signals (Action System).
Further modulation was suggested by other poorly understood mechanisms, including descend-
ing facilitatory and inhibitory mechanisms (Central Control).
In a tooth extraction site, the inamed area is marked by increased sensitiv-

ity to pressure (static hyperalgesia) that is mediated by sensitized nocicep-
tors. It is expected that this reaction will resolve within a reasonable
period of time due to the decreasing activity of the nociceptors and conse-
quent decrease in aerent activity to the dorsal horn. If the inammatory
process and consequent aerent activity is of sucient intensity and if there
has been neuronal damage, a central process is established that increases
sensitization, lowers the threshold of response, and causes ectopic discharges
(physiologic changes). Additionally, A-b bers begin signaling pain (dy-
namic mechanical allodynia), and their inhibitory eect is lost (anatomic
changes and disinhibition). There is now an increased central release of ex-
citatory mediators, such as glutamate and nitric oxide production (neuro-
chemical changes). These changes stimulate the MAP kinase cascades,
resulting in messenger RNAmediated changes that alter the phenotype of
nociceptors and mechanoreceptors such that normal cell response becomes
genetically changed to a pathologic state (Fig. 4).
Central sensitization is a form of neuroplasticity in which nociceptor ac-
tivity triggers a prolonged increase in the excitability of dorsal horn neurons.
It is initiated by a brief burst of C-ber activity. The peripheral manifesta-
tion of this central process is dynamic hyperalgesia. Torebjork [36] has pro-
vided evidence showing that once central sensitization has occurred, Ab
ber aerents begin to evoke painful response (allodynia) [36]. C-nociceptors
have been identied as the primary nociceptor involved in the initiation of
central sensitization due to the slow synaptic currents they generate and the
low-stimuli repetition rates that cause an increased rate of depolarization in
the dorsal horn [35]. This occurs as a result of the activation of ligand-gated
ion channels, initially the alpha-amino-3-hydroxy-5-methyl-4-isoxazole
50 MERRILL
2 1
Ca++
Ca++
Ras AC 3
Cell
Membrane TrK
cAMP
Ca++ PYK2 Raf-1 Ca++
PKC PKA
Ca ++
/CaM MEK Rap1 Ca++ /CaM
B-Raf Signal Transduction

CaMK-IV ERK/MAPK Pathways in
Nociception
RSK2
Nuclear CREB
Membrane
pCREB
CRE
Gene Transcription
Fig. 4. The MAP kinase cascades. This diagram illustrates the intracellular responses to noci-
ceptor depolarization. There are three main pathways of the MAP kinase cascades that result in
the stimulation of cAMP response element binding protein and in the transcription of genes that
produce target proteins altering the phenotypic expression of the nociceptors and postsynaptic
neurons in the nociceptive chain. The gene transcription causes long-term potentiation and cell
memory for pain. Abbreviations: CamK, calmodulin kinase; CRE, cAMP response element;
CREB, cAMP response element binding protein; ERK, extracellular signal-regulated protein
kinase; MAPK, mitogen-activated protein kinase; MEK, MAPK/ERK kinase; Ras/Raf-1, pro-
teins that are molecular switches in the MAPK pathway; TRK, tyrosine kinase
proprionate (AMPA) receptor allowing calcium to enter the cell through the
calcium channels. In addition, activation of the metabotropic glutamate and
neurokinin receptors by glutamate and substance P causes a G-protein
coupled transduction signal that releases calcium from intracellular stores,
further increasing the intracellular calcium levels. This calcium activates a
calcium-dependent enzyme system, including protein kinases that phosphor-
ylate the N-methyl-D-aspartate (NMDA) receptor. The NMDA receptor at
normal resting membrane potentials has a magnesium ion block in the
channel, but when the receptor is phosphorylated, the ion is released. Before
phosphorylation, the NMDA receptor generates little inward current when
glutamate is bound, but after phosphorylation and release of the ion channel
block, the NMDA receptor generates inward synaptic currents at normal rest-
ing membrane potentials [39]. This process causes increased glutamate sensi-
tivity and is the underlying mechanism that is represented by the expansion of
receptive elds and a decrease in the threshold of the dorsal horn neurons.
Ab bermediated dynamic hyperalgesia may also be the result of central
reorganization of neuronal connections in the dorsal horn. Woolf and
others [4,39] have found that A-b bers sprout into dorsal horn lamina I
and II after peripheral injury, forming new connections in areas normally

occupied only by c-ber nociceptors. These new connections can apparently
signal pain. Additionally, it has been reported that with the neuronal orga-
nization and transcriptional changes induced by the sensitization, Ab bers
begin expressing substance P, previously thought to be associated only with
c-bers [22]. mOpioid receptors are found presynaptically on c-bers but
not on A-b bers. Part of the descending inhibitory system uses endogenous
opioid action on presynaptic m-opioid receptor. Because these receptors are
not found on A-b bers, this may account for the relative lack of response to
opioid agonists in neuropathic pain.
The inux of calcium through voltage-gated ion channels also occurs on
the inhibitory interneurons in lamina II. Calcium may induce excitotoxic cell
death, resulting in a loss of inhibitory connections [33,38]. Mao and col-
leagues [17] showed that pretreatment with NMDA receptor antagonists
seemed to protect the dorsal horn from changes that produced prolonged
sensory hypersensitivity. Nitric oxide, arachidonic acid, superoxide, and in-
tracellular calcium overload are the ultimate mediators of neuronal death.
Pain-modulating circuits
Pain is strongly aected by emotions. In the presence of anger, fear, or
elation, major injury may be essentially painless. Conversely, in situations
associated with dysphoria or when pain is anticipated, subjects often report
the occurrence or worsening of pain without additional noxious stimulation.
Psychologic factors inuence the ring of dorsal horn pain transmission
neurons.
It has been observed that stimulation of the periaquaductal gray area in
the midbrain increased tail-ick latency in rats that were given a painful
stimulus. The periaquaductal gray area was demonstrated to be heavily in-
nervated with serotonergic neurons. Subsequently it has been demonstrated
that there are connections to the nucleus raphe magnus of the rostral ventral
medulla and thence to the nucleus caudalis of the trigeminal nucleus or the
dorsal horn of the spinal cord. This system is part of the descending inhib-
itory system mediated by serotonin. Additionally, a descending system mod-
ulated by norepinephrine travels from cortical stimulatory centers to the
periaquaductal gray and on to the dorsolateral pontine tegmentum area
of the medulla, also connecting to the relay neurons (wide dynamic range)
in the nucleus caudalis or dorsal horn. The dorsolateral pontine tegmentum
is directly linked to the periaquaductal gray and rostral ventral medulla and
projects directly to the spinal cord dorsal horn and the nucleus caudalis.
Pain modulation requires action from both circuits acting in tandem
(Fig. 5).
Many of the centrally acting medications used to modulate pain act
within these two systems to bring about a reduction of pain that does not
involve the opioid system and consequently does not build tolerance to
52 MERRILL
Cortex Thalamus
Hypothalamus
Mesencephalon PAG
Pons
DLP
NE
NG/NC
Medulla
RVM
DLF
5HT NE SST
Spinal
Cord
TNC
Periphery
Fig. 5. Pain-modulating circuitry in the dorsal horn. Action potentials from trigeminal nocicep-
tors enter the trigeminal nucleus caudalis (TNC), where they synapse with second-order neu-
rons. In the TNC, the relayed signals ascend in the spinothalamic tract (SST), going to the
rostroventromedial medulla (RVM) and through the nucleus gracilis (NG) from the lower
body or the nucleus cuneatus (NC) from the upper body to the periaquaductal gray (PAG),
the hypothalamus and thalamus where tertiary synapses occur. One of the major descending
inhibitory systems in the pathways is the linkage with the serotonergic cells of the PAG and
RVM. An additional inhibitory pathway involves a descending connection from the PAG to
the dorsolateral pontine tegmentum (DLP), which is modulated by norepinephrine. The inhib-
itory signals from the RVM and the DLP descend in the dorsolateral faniculus (DLF) to the
TNC, mediating TNC nociceptive activity. The information is transmitted to the cortex and
can be modulated (inhibited or disinhibited) through cortical inuence.
the eects of the medications. One of the most widely used classes of med-
ications for chronic pain is the tricyclic antidepressants. Medications such as
amitriptyline and nortriptyline are commonly used for central pain condi-
tions such as postherpetic neuralgia and diabetic neuropathy and work
within the serotonin system. Another tricyclic antidepressant, desipramine,
works primarily through the norepinephrine system. Their pain inhibitory
eects are not linked to the antidepressant eects.
Glial inuences on pain

Glial cells (microglia and astrocytes) have been viewed classically as sup-
port cells in the CNS and were not seen to have an active role in pain trans-
mission because they did not possess axons. This view has changed with
recent research, and there is evidence that glia have an important role in
the development of central sensitization. This role is being dened as re-
search explores the interactions from dorsal horn neurons to the glia and
the glia to the dorsal horn neurons. Consequently, glia are no longer viewed
as only passive support cells but as active participants in modulating pain
transmission and other types of neuronal activity in the CNS.
Synapses in the CNS are surrounded by glial cells, and neurotransmitter

receptors have been identied on these glia. The implication is that the glia
can respond to central neurotransmitter release from presynaptic nociceptor
endings [13,25]. Furthermore, transport mechanisms have been identied in
glia that oversee the uptake and release of neurotransmitters from the glia
[28,15]. More recently, glial cells have been shown to be involved in the de-
velopment of hyperalgesia due to nerve trauma and other conditions that
can lead to central sensitization [5,34].
Because glia possess receptors and transport mechanisms for neurotrans-
mitters, one might assume that they release neurotransmitters in the synap-
tic cleft that would have a presynaptic and postsynaptic eect on pain
modulation. Watkins [37] demonstrated that glia were involved in central
sensitization from nerve injury when hyperalgesia was reduce by disrupting
glial activation [37]. It has also been observed that glia are normally in-
volved only in pathologic pain processes [19].
The classical model of central sensitization did not include glial inuence,
but current evidence has shown that glial activation is intimately involved in
the central sensitization process.
Part of the mechanism responsible for enhancing glial-mediated central
sensitization is the release of the neurotransmitter nitric oxide, prostaglan-
dins, and excitatory amino acids such as glutamate that have been linked to
the development of central sensitization in the classic model [37]. A central
synaptic feedback loop has been described that involves the second-
order neurons and the central terminals of the nociceptors. Now, a similar
feedback loop is described between the glia and the central synaptic neurons
that would further aect central sensitization.
Impact of central sensitization on orofacial pain and temporomandibular

disorders
Myofascial pain
Myofascial pain probably represents a neurosensory disorder involving
peripheral and centrally sensitized muscle nociceptors. There are many char-
acteristics of the disorder that are best accounted for by equating the pain
phenomena with a neurosensory pathophysiology. For example, the pri-
mary indication of myofascial pain is the characteristic radiation of the
pain from the primary site of palpation to unrelated sites that can be in dif-
ferent dermatomes. This most likely occurs secondarily to central phenom-
ena, including convergence and activation of adjacent second-order
neurons, which would explain the expansion of the receptive eld, the low-
ering of the threshold to stimulation, and the allodynia associated with ac-
tive trigger points.
Simons proposed a central mechanism for the development of the disor-
der [12,2931]. He postulated that the muscle nociceptors, when activated by
54 MERRILL
peripheral injury, released substance P, which would diuse and spread be-
tween segments of the spinal cord to activate other adjacent nociceptors and
second-order neurons. As we now understand central sensitization, there are
many neurotransmitters and ion channels that become involved in the cen-
tral sensitization process in addition to glial activation (Fig. 6). The ultimate
result is activation of the NMDA receptors on the second-order neurons.
When the NMDA receptor is activated, the pain becomes modulated pri-
marily in the CNS and is only partially aected by peripheral mechanisms.
In neuropathic pain conditions, NMDA activation connotes a more pro-
tracted change in pain. In neuropathic pain, these changes seem to be per-
manently persistent or at least of long duration. Central sensitization has
also been associated with migraine. This situation does not typically have
an enduring impact on migraine because the headache tends to resolve
within hours. Timely treatment of the migraine can stop the sensitization,
and the headache will resolve, or if left untreated, will resolve by itself.
Therefore, the sensitization that occurs is of shorter duration. This may
be the case with myofascial pain.
C-PMN
NMDA Receptor
Activation and GTP cGMP
NO Production
GC-S GC-S
CGRP
NO
SP, EAAs SP
GLU
Glia NO Dyn
CGRP GLU SP
Ca++ CGRP NO
EAAs Dyn
SP
PG Mg++ GLU
SP SP
NMDA AMPA
NON
NMDA
Ca++
Second order Wide CaM NO
L-Arginine
Dynamic Range NADPH
NOS L-Citrulline
Neuron O2 Wilcox
Fig. 6. Glial activation and central sensitization. Classic description of central sensitization in-
volved central release neurotransmitters from nociceptors (C-PMN) that caused a cascade of
events in the second-order neuron, including activation of the NMDA receptor and opening
of its ion channel, allowing calcium to ow into the wide dynamic range neurons. The calcium
interacts with the calmodulin protein complex, nitric oxide synthetase, and L-arginine to form
nitric oxide (NO). NO diuses out of the postsynaptic neuron and stimulates further release of
excitatory amino acids (EAAs) and neurokinins from the presynaptic buton to continue the
process. This process is understood to be enhanced by a similar response in the glial cells (glial
activation).
Although the focus of this article is on central sensitization, peripheral

sensitization needs to be considered as a component leading to central
changes. If myofascial pain is a disorder with characteristics of peripheral
and central sensitization, the other phenomena of myofascial pain become
more understandable. For example, the trigger point may represent periph-
eral sensitization of muscle nociceptors. A component of peripheral sensiti-
zation is the activation of nociceptors that release neurotransmitters such as
substance P, calcitonin gene related peptide (CGRP), and prostaglandins.
These neurotransmitters cause a localized inammatory reaction by acting
on neurokinin and prostaglandin receptors on the nociceptors and on the
blood vessels resulting in the expansion of the blood vessels and plasma
extravasation (swelling taut bands), increased pain with palpation (local
allodynia and twitch response) at the site neurotransmitter release, and
expansion of the pain into the area immediately around the site (static
mechanical allodynia decreased threshold to palpation resulting in twitch
response). The dorsal horn reex causes muscle tightening when the noci-
ceptors relay pain to the dorsal horn. These mechanisms are consistent
with mechanism of peripheral sensitization in neuropathic pain. The action
of trigger point injections also would be consistent with peripheral neuro-
sensory mechanisms when myofascial pain is viewed as a neurosensory dis-
order. Injecting a local anesthetic would block sodium channels in the pain
bers, stopping the release of neurotransmitters peripherally and centrally.
The net eect of this would be to decrease the local neurogenic inamma-
tory response. Heating the area, stretching the muscle bers, and the irrita-
tion by dry needling would increase the blood ow to the area, diluting or
washing out the neurotransmitters and eventually decreasing the neurogenic
inammation. Centrally, these eects decrease the release of neurotransmit-
ters that are responsible for the central sensitization that is characterized by
expansion of the peripheral receptive eld and autonomic activation
through parasympathetic ber release of norepinephrine.
Temporomandibular joint pain

Pain of the temporomandibular joint (TMJ) joint is commonly associated
with redness and swelling and allodynia of the skin over the joint. These re-
actions are modulated by release of peripheral neurotransmitters in the joint
space, causing peripheral sensitization. Occasionally, an inamed joint con-
tinues to be painful despite appropriate treatment aimed at decreasing joint
inammation and pain. In some patients, attempting to quell the joint
inammation with intracapsular injections can be met with a signicant in-
crease rather than a decrease in pain. This reaction may be seen in patients
who have had long-standing TMJ inammation subsequent to trauma or
surgery. This reaction is dicult to manage with traditional conservative
TMJ therapy. The clinician may begin to suspect that a centralized neurop-
athy has developed in the joint. These joints may not respond to local
56 MERRILL
anesthetic injections, and, if epinephrine is injected with the local anesthetic,

the pain can become signicantly worse, suggesting that sympathetically me-
diated pain has developed. Often, these patients are recommended to have
another surgery to try to correct what is thought to be a musculoskeletal
problem but which is a peripheral or central neuropathy. Temporomandib-
ular joints can develop peripheral and centralized neuropathy, and once this
occurs, the treatment needs to focus on the types of treatment used in neu-
ropathic pain, such as antiseizure medications, tricyclic antidepressants, nar-
cotics, and sympathetic ganglion blocks to evaluate for sympathetically
mediated pain.
Neurovascular disorders
Neurovascular disorders relate primarily to headaches. Until recently, the
science of headache disorders did not try to equate them with known
mechanisms of central neurophysiology. Burstein [2,3,16,32] published
several articles in the late 1990s that showed that migraine and other head-
ache disorders were aected by the same central pathophysiology as neuro-
pathic pain. The mechanisms of central sensitization made some of the
characteristics of migraine more understandable, such as the lack of re-
sponse to analgesics and triptans, if they are taken too late in the develop-
ment of the headache attack. Additionally, the development of central
sensitization causes static and dynamic mechanical allodynia of the head
and neck, including the masticatory and cervical muscles. It is not uncom-
mon for a patient to report to an OFP clinician that they get moderate to
severe jaw and neck pain with a headache. When a patient is seen during
one of these attacks, administration of a triptan or DHE-45 can stop the at-
tack and relieve the jaw and neck pain within minutes. The clinician needs to
dierentiate between jaw and neck pain due to secondary or central sensiti-
zation associated with headache and headache due to painful TMJ and
muscle inputs into the CNS that result in headache. In the rst case, treating
the headache relieves the muscle pain; in the last case, treating the muscle
pain can relieve the headache.
Neuropathic pain
Neuropathic pain is commonly seen in the orofacial region. It may develop
as a consequence of trauma, simple dental treatment, extractions, endodontic
treatment, oral surgery, implants, or orthognathic surgery. The development
of a neuropathy does not imply improper or poor treatment. It is not under-
stood why some dental patients develop neuropathies when most do not,
even in the face of fairly severe neurotrauma that can occur in everyday general
dentistry. Researchers are beginning to suspect that there is a genetic diathesis
due to variables such as receptor polymorphism that may predispose someone
to develop a neuropathy [6].
Neuropathic pain in the oral environment due to central sensitization is

characterized by chronic aching and burning pain that is persistent over
a 24-hour period but which may uctuate in intensity during this time.
The distinguishing characteristic of centralized neuropathic pain is the
lack of response to a topical, local, or regional anesthetic. Neurosensory
testing may nd that the painful area has pin-prick hyperalgesia and dy-
namic mechanical allodynia. These neurosensory responses are mediated
by central sensitization and A-b ber stimulation. The classical dental
term for this oral neuropathy is atypical odontalgia [10,11]. Marbach,
in the 1990s, suggested that they were phantom tooth pains [40]. Neither
of these terms indicates a mechanism behind the pain. In reviewing the char-
acteristics of these two conditions, it becomes apparent that both are
describing peripheral and central neuropathies. A more useful title should
reference the likely mechanism underpinning the condition. If the tooth
pain is blockable and is characterized by static mechanical allodynia, it is
a chronic peripheral neuropathy. If the tooth pain is not blockable and is
characterized by dynamic mechanical allodynia or pinprick hyperalgesia,
it is a chronic centralized neuropathy [9]. Treatment of these conditions dif-
fers, and it is important to distinguish whether the pain is due to peripheral
sensitization or central sensitization.
Summary
The orofacial pain clinician must understand the dierence between pe-
ripheral and central mechanisms of pain. Particularly, one has to under-
stand the process of central sensitization as it relates to the various
orofacial pain conditions to understand orofacial pain. Understanding leads
to more eective treatment.
References
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[3] Burstein R, Cutrer MF, Yarnitsky D. The development of cutaneous allodynia during a mi-
graine attack clinical evidence for the sequential recruitment of spinal and supraspinal noci-
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Dent Clin N Am 51 (2007) 6183
Myogenous Temporomandibular
Disorders: Diagnostic and Management
Considerations
James Fricton, DDS, MS
Diagnostic and Biological Sciences, University of Minnesota School of Dentistry,
6-320 Moos, Minneapolis, MN 55455, USA
Myogenous temporomandibular disorders (or masticatory myalgia) are

characterized by pain and dysfunction that arise from pathologic and func-
tional processes in the masticatory muscles. There are several distinct muscle
disorder subtypes in the masticatory system, including myofascial pain,
myositis, muscle spasm, and muscle contracture (Box 1) [1].
Myofascial pain is the most common muscle pain disorder [2]. It is an
acute to chronic condition that includes the presence of regional pain asso-
ciated with tender areas, called trigger points (TrPs), which are expressed in
taut bands of skeletal muscles, tendons, or ligaments. Although the pain oc-
curs most often in the region over the TrP, pain can be referred to areas dis-
tant from the TrPs (eg, temporalis referring to the frontal area and masseter
referring into the ear or the posterior teeth). Often, reproducible duplication
of pain complaints with specic palpation of the tender area is diagnostic.
Myositis is an acute condition with localized or generalized inammation
of the muscle and connective tissue, and associated pain and swelling over-
lying the muscle. Most areas in the muscle are tender, with pain in active
range of motion. Usually, the inammation is due to local causes, such as
overuse, excessive stretch, drug use (ie, Ecstasy), local infection from peri-
coronitis, trauma, or cellulitis. It also is termed delayed-onset muscle sore-
ness in cases of acute overuse.
Muscle spasm also is an acute disorder that is characterized by a brief in-
voluntary tonic contraction of a muscle. It can occur as a result of over-
stretching of a previously weakened muscle; protective splinting of an
injury; as a centrally mediated phenomenon, such as Compazine-induced
62 FRICTON
Box 1. Diagnostic criteria for masticatory myalgia disorders

Myofascial pain: repetitive strain
Dull aching pain in the jaw, face, ear, temples, or forehead
Localized tenderness (TrPs) in specific taut muscle bands with
tenderness on the same side as the pain. See Fig. 1 for sites
and referral patterns.
Duplicate the pain with palpation of the tender TrPs
Muscle spasm: acute overuse
Acute onset of pain in the jaw, face, ear, or temples at rest and
in function
Moderate to severe acute limited range of motion due to
continuous muscle contraction. In lateral pterygoid spasm, the
jaw has a shift to one side with subsequent acute malocclusion
that is reversible.
Generalized tenderness of the muscle
Myositis: injury or infection
Pain, usually continuous, in a localized muscle area following
injury or infection that is increased with mandibular
movement.
Diffuse tenderness over the entire muscle area involved
Moderate to severe limited range of motion
Swelling over muscle area involved
Muscle contracture: muscle fibrosis
Gross limited range of mandibular motion
Unyielding firmness on passive stretch (hard end feel)
Little or no pain unless the involved muscle is forced to
lengthen
Long-term history of trauma, infection, or long period of disuse
and limited range of motion
spasm of the lateral pterygoid muscle; or overuse of a muscle. A muscle in

spasm is acutely shortened, and painful, with limited range of motion. Lat-
eral pterygoid spasm on one side also can cause a shift of the occlusion to
the contralateral side.
Muscle contracture is a chronic condition that is characterized by contin-
uous gross shortening of the muscle with signicant limited range of motion.
It can begin because of factors such as trauma, infection, or prolonged hy-
pomobility. If the muscle is maintained in a shortened state, muscular bro-
sis and contracture may develop over several months. Often, pain can be
minimal in the process from protection of the muscle.
MYOGENOUS TEMPOROMANDIBULAR DISORDERS 63
Clinical presentation
The major characteristics of masticatory myalgia include pain, muscle
tenderness, limited range of motion, and other symptoms, such as fatigabil-
ity, stiness, and subjective weakness. Comorbid conditions and complicat-
ing factors also are common and are discussed. Each is discussed for the
dierent subtypes.
Pain
The common sites of pain in the masticatory system include jaw pain; facial
pain; temple, frontal, or occipital headaches; preauricular pain; earache; and
neck pain. Often, the pain is a constant steady dull ache that uctuates in in-
tensity and can be acute to chronic. The duration may vary from hours to days.
Muscle tenderness
In myofascial pain (MFP), the tenderness, termed trigger points (TrPs), is
deep, localized, and about 25 mm in diameter. It is located in a taut band
of skeletal muscle and is associated with consistent patterns of pain referral,
whereas in myositis and muscle spasm, the tenderness can be generalized
over the whole muscle. Myofascial TrPs are common and may be active
or latent. Active TrPs are hypersensitive and display continuous pain in
the zone of reference that can be altered with specic palpation. Latent
TrPs display only hypersensitivity with no continuous pain. This localized
tenderness is a reliable indicator of the presence and severity of MFP with
manual palpation and pressure algometers [35]; however, the presence of
taut bands seems to be a characteristic of skeletal muscles in all subjects, re-
gardless of the presence of MFP. Palpating the active TrP with sustained
deep, single-nger pressure on the taut band elicits an alteration of the
pain (intensication or reduction) in the zone of reference (area of pain com-
plaint) or causes radiation of the pain toward the zone of reference. This can
occur immediately or be delayed a few seconds. The pattern of referral is re-
producible and consistent with patterns of other patients who have similar
TrPs (Fig. 1). This enables a clinician to use the zone of reference as a guide
to locate the TrP for purposes of treatment.
Limited range of motion

In myofascial pain, limitation in range of motion may be slight (10%
20%) and unrelated to joint restriction, whereas in muscle spasm, myositis,
and contracture, it may be gross limitation (R50%). A study of jaw range of
motion in patients who had MFP and no joint abnormalities demonstrated
a slightly diminished range of 35 to 45 mm (w10% compared with normals)
and pain in full range of motion. This is considerably less limitation than
was found with joint locking that is due to a temporomandibular joint
64 FRICTON
Fig. 1. Trigger points in myofascial pain associated with local or distant patterns of pain refer-
ral in the jaw, head, and neck, as indicated by the white circles. (A) The pain source is the an-
terior temporalis trigger point. The pain sites include temple, frontal, and retro-orbital
headaches and pain in the maxillary anterior teeth. These muscles are activated by clenching,
bruxism, and other oral parafunctional habits. (B) The pain source is the deep masseter trigger
point. The pain sites include preauricular pain, earaches, and pain in the maxillary posterior
teeth. These muscles also are activated by clenching, bruxism, and other oral parafunctional
habits. (C) The pain source is the middle masseter trigger point. The pain sites include temple,
frontal, and retro-orbital headaches and pain in the maxillary anterior teeth. These muscles also
are activated by clenching, bruxism, and other oral parafunctional habits. (D) The pain source
is the splenius capitus trigger point in the posterior cervical area. The pain sites include posterior
cervical region, vertex headache, and frontal headaches. These muscles also are activated by
clenching and forward head posture.
(TMJ) internal derangement (2035 mm) [6]. This restriction may perpetu-
ate the TrP and develop other TrPs in the same muscle and agonist muscles.
This can cause multiple TrPs with overlapping areas of pain referral and
changes in pain patterns as TrPs are inactivated. Other causes of diminished
mandibular opening, which include structural disorders of the TMJ (eg, an-
kylosis, internal derangements, coronoid hypertrophy, gross osteoarthritis),
must be ruled out with radiographs and clinical examination.
Other symptoms
Other associated signs and symptoms may occur, including increased
fatigability, stiness, subjective weakness, and pain in movement; otologic
symptoms, including dizziness, tinnitus, and plugged ears; paresthesias,
including numb feelings, decreased sensation, and tingling; and dermatogra-
phia, including increased redness of the skin upon palpation or rolling. The
aected muscles also may display an increased fatigability, stiness, subjec-
tive weakness, pain in movement, and slight restricted range of motion that
is unrelated to joint restriction [1,710]. The muscles are painful when
stretched, which causes the patient to protect the muscle through poor pos-
ture and sustained contraction [11]. No neurologic decits are associated
with muscle pain disorders unless a nerve entrapment syndrome with weak-
ness and diminished sensation coincides with the muscle tightness. Although
routine clinical electromyographic (EMG) studies show no signicant ab-
normalities associated with TrPs, some specialized EMG studies reveal dif-
ferences [1215]. The consistency or rmness of soft tissues over the TrPs
has been found to be more than adjacent muscles [16,17]. Skin overlying
the TrPs in the masseter muscle seems to be warmer as measured by infrared
emission [18,19].
Comorbid conditions and complicating factors

There are many comorbid conditions to myogenous temporomandibular
disorder (TMD) pain that reect common etiologic factors and mechanisms
of pain. In most recent classications, the regional pain that is found with
MFP is distinguished from the widespread muscular pain that is associated
with bromyalgia (FM). These two disorders have similar characteristics
and may represent two ends of a continuous spectrum. For example, as
Simons [20] pointed out, 16 of the 18 tender point sites in FM lie at well-
known TrP sites. Many of the clinical characteristics of FM, such as fatigue,
morning stiness, and sleep disorders, also can accompany MFP. Bennett
[21] compared these two disorders and concluded that they are two distinct
disorders that may have a similar underlying pathophysiology. The clinical
signicance of distinguishing between them lies in the more common cen-
trally generated contributing factors in FM (sleep disorders, depression,
stress) versus the more common regional contributing factors in MFP
(trauma, posture and muscle tension habits) as well as the better prognosis
in treatment of MFP as compared with FM.
Other comorbid conditions that often have been cited to accompany my-
ogenous disorders include joint disk displacement and osteoarthritis, maloc-
clusion and functional occlusal dysfunction, connective tissue diseases,
neuropathic pain disorders, migraine and tension-type headaches, gastroin-
testinal disorders, and hypothyroidism. The underlying mechanism for the
coexistence of these comorbid conditions is not clear. Common underlying
central and peripheral mechanisms and etiologies may play a role.
66 FRICTON
Furthermore, many associated behavioral and psychosocial factors can

accompany the chronic pain that is associated with myogenous disorders.
Behavioral factors include muscle tension, oral parafunctional, and malad-
aptive postural habits; psychological factors include frustration, anxiety,
and depression; secondary gain from pain behaviors include pain verbaliza-
tion and avoidance of activities, medication dependencies, and sleep
disturbance.
Etiology and epidemiology

Prevalence
Muscle pain disorders are the most common cause of persistent pain in
the head and neck; they aect about 50% of a population that has chronic
head and neck pain population [22]. They also are a common cause of
pain in the general population, with 20% to 50% having the disorder;
about 6% have symptoms that are severe enough to warrant treatment
[23,24].
Etiologic factors
Onset factors for myogenous TMDs include direct or indirect macro-
trauma to the muscle and repetitive strain activities [9]. Macrotraumatic
events include a direct blow to the jaw, and opening the mouth too wide
or for too long a period during activities, such as dental visits, eating, yawn-
ing, and sexual activity. In some cases, indirect trauma that is due to a whip-
lash-type of injury may initiate muscle pain. Local infection and trauma
may cause myositis and lead to muscle contracture if not resolved. Occupa-
tional and repetitive strain injury may cause myofascial pain and muscle
spasm if acute. Sleep disturbance and nocturnal habits can contribute to my-
ofascial pain.
Oral parafunctional muscle tensionproducing habits, such as teeth
clenching, jaw thrusting, gum chewing, and jaw tensing can add repetitive
strain to the masticatory muscles and cause tenderness and pain. Postural
strain that is caused by a forward head posture, increased cervical or lumbar
lordosis, some occlusal abnormalities, and poor positioning of the head or
tongue also have been implicated in myofascial pain. Psychosocial stressors,
such as relationship conicts, monetary problems, feeling hurried or over-
scheduled, or poor pacing skills can play an indirect role.
Pathophysiology and mechanisms

Because there are no specic anatomic changes with myogenous pain, no
conclusive mechanisms are identied in cases of non-traumatic etiology.
Thus, several processes may explain the development and persistence of

masticatory myogenous pain [9].
Repetitive strain hypotheses

Repetitive strain from oral parafunctional habits contribute to localized
progressive increases in oxidative metabolism and depleted energy supply (de-
crease in the levels of ATP, ADP, and phosphoryl creatine; abnormal tissue
oxygenation). These changes result in the muscle nociception, particularly
with type I muscle ber types associated with static muscle tone and posture.
Tenderness and pain in the muscle involve types III and IV muscle nociceptors
that are activated by noxious substances, such as potassium, histamine, kinins,
or prostaglandins, which are released locally and cause tenderness.
Neurophysiologic hypothesis
Tonic muscular hyperactivity may be a normal protective adaptation to pain
instead of its cause. Phasic modulation of excitatory and inhibitory interneurons
that are supplied by high-threshold sensory aerents may be involved.
Central hypotheses
Convergence of multiple aerent inputs from the muscle and other vis-
ceral and somatic structures in the lamina I or V of the dorsal horn on
the way to the cortex can result in perception of local and referred pain [10].
Central biasing mechanism

Multiple peripheral and central factors may inhibit or facilitate central in-
put through modulatory inuence of the brain stem. This may explain the
diverse factors that can exacerbate or alleviate the pain, such as stress, repet-
itive strain, poor posture, relaxation, medications, temperature change, mas-
sage, local anesthetic injections, and electrical stimulation.
Diagnostic tests
Typically, the diagnoses of masticatory myalgia are determined through
clinical diagnostic criteria (see Box 1); however, some diagnostic strategies
can be helpful. In myofascial pain, injections of local anesthetic into the ac-
tive TrP reduce or eliminate the referred pain and the tenderness. Generally,
blood and urine studies are normal unless caused by a concomitant disorder.
Imaging studies, including radiographs and MRI, are normal. Routine clin-
ical EMG studies are abnormal in muscle spasm only. Some specialized
EMG studies (twitch response) reveal dierences in myofascial pain. Pain
questionnaires, such as the Chronic Pain Battery and TMJ Scale, may iden-
tify contributing factors, including emotional issues, somatization, second-
ary gain, and disability.
68 FRICTON
Treatment
Simple to complex
Myogenous pain can range from simple cases with transient single muscle
syndromes, to complex cases that involve multiple muscles and many inter-
relating contributing factors. Many investigators have found success in
treating myogenous pain using a wide variety of techniques, such as exercise,
TrP injections, vapocoolant spray and stretch, transcutaneous electrical
nerve stimulation, biofeedback, posture correction, tricyclic antidepressants,
muscle relaxants and other medications, and addressing perpetuating fac-
tors [12,2325]. The diculty in management lies in the critical need to
match the level of complexity of the management program with the com-
plexity of the patient. Failure to address the entire problem, including all in-
volved muscles, concomitant diagnoses, and contributing factors, may lead
to failure to resolve the pain and perpetuation of the pain.
Although no controlled studies have examined the progression of chronic
pain syndromes, results from clinical studies reveal that many patients who
have muscle pain have seen many clinicians, or received numerous medica-
tions and multiple other singular treatments for years without more than
temporary improvement. In one study of 164 patients who had muscle
pain, the mean duration of pain was 5.8 years for men and 6.9 years for
women, with a mean of 4.5 clinicians seen [23]. In another study of 102 con-
secutive patients who had TMJ and craniofacial pain (59.8% had muscle
pain), the mean duration of pain was 6.0 years, with 28.8 previous treatment
sessions, 5.1 previous doctors, and 6.4 previous medications [26].
These and other studies of chronic pain suggest that regardless of the
pathogenesis of muscular pain, a major characteristic of some of these patients
is the failure of traditional approaches to resolve the problem. Each clinician
who is confronted with a patient who has muscle pain needs to recognize
and address the whole problem to maximize the potential for a successful
outcome. Treating only those patients whose complexity matches the treat-
ment strategy that is available to the clinician can improve success. Typi-
cally, simple cases with minimal behavioral and psychosocial involvement
can be managed by a single clinician with self care as the initial focus of
care (Box 2). Complex patients should be managed within an interdisci-
plinary pain clinic setting that uses a team of clinicians to address dierent
aspects of the problem in a concerted fashion (Box 3). Fig. 2 presents a hi-
erarchy of treatment strategies, depending on whether the condition is
acute, simple, or complex.
The short-term goal is to restore the muscle to normal length, posture,
and full joint range of motion with exercises and TrP therapy (Box 4).
This is followed long term with a regular muscle stretching, postural, and
strengthening exercise program as well as control of contributing factors.
Long-term control of pain depends on patient education, self-responsibility,
Box 2. Palliative self-care program for acute episodes

of masticatory myalgia
Eat a soft diet and avoid caffeine.
Keep your tongue up and resting gently on the palate. Keep teeth
apart as the rest position of the jaw.
Chew on both sides at the same time or alternate sides to
minimize strain to muscles.
Avoid oral parafunctional habits, such as clenching and grinding
the teeth, jaw tensing, or gum chewing.
Avoid excessive or prolonged opening of mouth.
Avoid stomaching sleeping to minimize strain to the jaw during
sleep.
Use over-the-counter analgesics or nonsteroidal anti-
inflammatory drugs as needed for pain.
Use heat or ice over the tender muscles.
and development of long-term doctorpatient relationships. This often re-

quires shifting the paradigms that are implicit in patient care (Table 1). Of-
ten, the diculty in long-term management lies not in treating the TrPs, but
rather in the complex task of changing the identied contributing factors,
because they can be integrally related to the patients attitudes, lifestyles,
and social and physical environment. Interdisciplinary teams integrate var-
ious health professionals in a supportive environment to accomplish long-
term treatment of illness and modication of these contributing factors
Box 3. Fulfilling any one of these criteria may suggest that this
patient is complex and may require the use of the team to
address the contributing factors and increase the prognosis
Persistent pain (daily or regular) that is longer than 6 months
in duration
Significant lifestyle disturbances, such as loss of work, social
activities, or home activities
High use of past health care, including medications for problem
or related problems
Emotional difficulties related to problem, including depression,
anxiety, or anger
Daily oral habits, such as clenching or grinding of the teeth
Significant stressful life events, such as pacing problems,
divorce, or recent death in family
70 FRICTON
Acute:
Onset in past weeks Acute Treatment (weeks):
No Previous Treatment Spray and stretch
One episode of pain Home stretching and posture
One or 2 muscles with trigger points Oral habit reversal/ soft diet
No joint involvement
Acute strain involved
Simple Treatment (months):

Simple:
Spray and stretch
Onset in past months Home stretching and posture
Minimal previous treatment Intraoral splint
Episodic and regional pain Anti-inflamatories/ Muscle relaxants
Regional muscles with trigger points Oral habit reversal/ soft diet
Behavioral factors involved Selected trigger point injections
Complex Treatment (1 year):

Chronic:
Interdisciplinary Team
Onset more than 6 months ago
Home stretching and posture
Many unsuccessful treatments
Intraoral splint
Multiple regions of persistent pain
Anti-depressants
Widespread trigger points
Trigger point injections
Many behavioral factors involved
Oral habit reversal/ soft diet
Pyschosocial factors involved
Counseling for depression/ anxiety,
Stress management
Fig. 2. Treatment strategies dier depending on whether the condition is acute, simple, and
complex.
(Box 4). Many approaches, such as habit reversal techniques, biofeedback,

and stress management have been used to achieve this result within a team
approach (Box 5).
Management follows these goals and includes self-care, muscle exercises,
muscle therapy, and reducing all contributing factors; it is directed at reha-
bilitating the muscle to improving range of motion, reducing tenderness,
and reducing or eliminating contributing factors. Muscle rehabilitation is fo-
cused on exercise to improve range of motion, relaxation, and strength of
the muscle. Reduction of contributing factors includes reducing biomechan-
ical strain to the muscles from oral parafunctional habits, such as clenching,
gum chewing, and other repetitive strain activities. In addition, improved
posture of the head, neck, and tongue reduces sustained muscle activity
and encourages healing. Reducing tenderness can be accomplished by inhib-
iting peripheral neural input through various treatment modalities, such as
cold, heat, analgesic medications, massage, muscle injections, and transcuta-
neous electrical nerve stimulation. Reducing central modulating factors,
include management of contributing factors (eg, improving stress, sleep,
anxiety, and depression).
Box 4. Short- and long-term goals in treatment of myofascial

pain
Short-term goals
Reduce pain
Restore muscle to normal length with full joint range of motion
Restore muscle to normal posture
Reduce sustained muscle activity
Long-term goals
Restore normal lifestyle activities
Reduce contributing factors
Regular stretching, postural, and conditioning exercises
Proper use of muscles
Self-care
Most acute recent symptoms are self-limited and resolve with minimal in-
tervention. Initial treatment should be a self-care program to reduce repet-
itive strain of the masticatory system and encourage relaxation and healing
of the muscles (see Box 2).
This strategy includes jaw range of motion and posture exercises (Fig. 3),
oral habit change, and protective gentle use of the jaw. Most patients respond
well to self-care in 4 to 6 weeks; if not, further assessment and treatment are
indicated.
Orthopedic intraoral splints

These can encourage relaxation of the muscles, alter muscular recruitment
patterns, and reduce oral habits. Stabilization splints allow passive protection
of the jaw and reduction of oral habits as the result of the at passive occlusal
surface on mandibular or maxillary teeth. Mandibular splints can be smaller
and result in higher patient satisfaction in some cases. They should be
Table 1
Shifting the doctor-patient paradigms involves each member of the team following the same
concepts by conveying the same messages implicit in their dialogue with the patient
Concept Statement
Self-responsibility You have more inuence on your problem than we do
Self-care You will need to make daily changes to improve your
condition
Education We can teach you how to make the changes
Long-term change It will take at least 6 months for the changes to have an
eect
Doctor-patient relationship We will support you as you make the changes
Patient motivation Do you want to make the changes?
72 FRICTON
Box 5. Protocol checklist for managing masticatory and cervical

myalgia pain
Evaluation
Identify masticatory and cervical muscles involved
Identify each area of pain
Frequency
Duration
Intensity
Identify contributing factors
Direct macrotrauma (eg, blow to jaw)
Indirect macrotrauma (eg, whiplash injuries)
Postural habits in the neck and shoulders (eg, phone bracing,
shoulder shrugging, neck tensing)
Oral parafunctional habits (eg, clenching and grinding
of teeth)
Dietary factors (eg, caffeine)
Sleep disturbance
Psychosocial stressors
Anxiety and depression
Determine simple versus complex
Simple: single clinician evaluation and treatment
Complex: team evaluation including dentist, physical therapist
or chiropractor, psychologist
Management
Acute care with palliative self-care
Simple case management with single clinician
Self-care
Splint
Jaw exercises
Vapocoolant spray or other modality with stretching
Oral habit and muscle relaxation and posture instruction
Complex case management with the team
Self care
Splint
Trigger point or muscle injections
Medications (muscle relaxants and anti-inflammatory drugs
as needed)
Exercises with physical therapist
Cognitive-behavioral therapy
Counseling as needed
Fig. 3. (A, B) Jaw exercises. These jaw stretching exercises can be used for initial postural cor-
rection and range of motion restoration for masticatory myalgia. 1) Active stretching of the
muscles increases the opening to the normal range and decreases the pain. The jaw should be
stretched progressively slightly beyond the point of tightness and pain. Precautions should be
made to avoid overstretching with acutely strained jaws or severe pain of the TMJ. Place one
nger between your teeth for one minute. Rest and repeat. Then place two ngers between
your teeth for one minute. Stretching can continue over weeks to months to achieve a three n-
ger stretch. 2) Jaw relaxed with tongue up and teeth apart. Place the at tip of the tongue gently
on the palate (roof of the mouth) wherever it is most comfortable, while allowing the teeth to
come apart and the jaw to be relaxed. The position of the tongue when you say n is often
a comfortable position. Do not touch the teeth together at all during the day except occasion-
ally; they touch lightly with swallowing.
adjusted to achieve mutually protected occlusion with bilateral balanced con-

tact on all posterior teeth with the condyles in their most seated positions, with
anterior guidance (lateral and protrusive) provided by the cuspids or incisors.
Anterior repositioning splints can be ecacious for concomitant joint
problems with intermittent jaw locking with limited range of motion, espe-
cially upon awakening. They are recommended for short-term, part-time
use, primarily during sleep, because they can cause occlusal changes if
worn continuously or chronically.
Partial coverage splints may cause occlusal changes in some patients.
Splints should cover all of the mandibular or maxillary teeth to prevent
movement of uncovered teeth, with malocclusion.
Cognitive-behavioral therapy
Cognitive-behavioral therapy approaches can help to change maladaptive
habits and behaviors that contribute to myalgia, such as jaw tensing, teeth
clenching, neck and shoulder tensing, and teeth grinding. Although many
74 FRICTON
simple habits are abandoned easily when the patient becomes aware of them,
changing persistent habits requires a structured program that is facilitated by
a clinician who is trained in behavioral strategies. Habits do not change them-
selves. Patients are responsible for initiating and maintaining behavior changes.
Habit reversal can be accomplished by becoming more aware of the
habit, knowing how to correct it (ie, what to do with the teeth and tongue
or neck and shoulders), and knowing why to correct it. Combining the pa-
tients commitment to conscientious self-monitoring and the patients focus
upon the goal, habits will gradually change over several weeks time. Fur-
thermore, correcting the habits such as clenching during the day will help
to reduce them at night. This can be supplemented with additional behav-
ioral strategies, such as biofeedback, meditation, stress management, or re-
laxation techniques as needed. It also is important to address poor pacing or
hurrying that is related to a day that is overloaded with commitments. In
addition, addressing other contributing factors such as depression, anxiety,
sleep disorders, and emotional problems through behavioral and psycho-
logic therapy or medications may be critical to success.
Muscle exercises
The most useful exercise techniques for muscle rehabilitation include
muscle stretching, posture, strengthening, and relaxation exercises
[12,24,25,27,28]. In patients who have muscle pain, a home program of ac-
tive and passive muscle stretching exercises reduces the activity of muscle
pain, whereas postural exercises reduce its susceptibility to reactivation of
pain by physical strain (see Fig. 3). Strengthening and cardiovascular tness
exercises improve circulation, strength, and durability of the muscles. Relax-
ation exercise can help reduce repetitive tensing and strain of the muscles.
Evaluating the present range of motion of muscles is the rst step in pre-
scribing a set of exercises to follow. For example, in the head and neck,
range of motion should be determined for the jaw and neck at the initial
evaluation. A limited mandibular opening in the jaw indicates if there is
any pain within the elevator muscles: temporalis, masseter, and medial pter-
ygoid. If mandibular opening is measured as the interincisal distance, the
maximum range of opening is generally between 42 mm and 60 mm or ap-
proximately three knuckles width (nondominant hand). A mandibular
opening in the masseter is approximately 30 mm to 40 mm or two knuckles
width. If contracture of masticatory muscles is present, the mandibular
opening can be as limited as 10 mm to 20 mm. Other causes of diminished
mandibular opening include structural disorders of the TMJ, such as anky-
losis, internal derangements, and gross osteoarthritis.
Passive and active stretching of the muscles increases the opening to the
normal range and decreases the pain. Passive stretching of the masticatory
muscles during counterstimulation of the tender muscle can be accom-
plished through placing tongue blades between the incisors or placing gentle
pressure between the incisors with the thumb and middle nger while the
spray-and-stretch technique is accomplished. It must be emphasized to
avoid rapid, jerky stretching or overstretching of the muscle to reduce po-
tential injury to the muscle.
Postural exercises are designed to teach the patient mental reminders to
hold the body in a balanced relaxed position and to use the body with positions
that aord the best mechanical advantage. This includes static postural prob-
lems, such as unilateral short leg, small hemipelvis, occlusal discrepancies, and
scoliosis, or functional postural habits (eg, forward head, jaw thrust, shoulder
phone bracing, lumbar lifting). In a study of postural problems in 164 patients
who had head and neck muscle pain, poor sitting/standing posture in 96%,
forward head in 84.7%, rounded shoulders in 82.3%, lower tongue position
in 67.7%, abnormal lordosis in 46.3%, scoliosis in 15.9%, and leg length dis-
crepancy in 14.0% contributed to muscle pain [23]. In improving posture, spe-
cic skeletal conditions, such as structural asymmetry or degenerative joint
changes need to be considered. In the masticatory system, the patient should
be instructed to place the tongue gently on the roof of the mouth and keep the
teeth slightly apart. In the cervical spine, a forward or lateral head posture
must be corrected by guiding the chin in and the head vertex up. The shoulders
fall back naturally if the thorax is positioned up and back with proper lumbar
support. Patients need to be instructed in proper posture for each positiond
sitting, standing, and lying downdas well as in movements that are done re-
petitively throughout the day, such as lifting or turning the head to the side.
Sleeping posture on the side or back is particularly important for patients
who wake up with soreness.
Improved posture also is facilitated by regular physical exercise and con-
ditioning. Patients need to be placed on a conditioning program to facilitate
increased exibility, aerobic capacity and strength. Exercise programs, such
as yoga, an exercise class, regular running, walking, biking, or swimming
improve the comfort, exibility, endurance, and functional status of patients
who have muscle pain [6].
Muscle therapy
Many methods have been suggested for providing repetitive stimulation
to tender muscles. Massage, acupressure, and ultrasound provide noninva-
sive mechanical disruption to reduce tenderness. Moist heat applications, ice
pack, vapocoolant spray, and diathermy provide skin and muscle tempera-
ture change as a form of counterstimulation. Transcutaneous electrical
nerve stimulation, electroacupuncture, and direct current stimulation pro-
vide electric currents to stimulate the muscles and TrPs. Acupuncture or
TrP injections of local anesthetic, corticosteroids, or saline cause direct me-
chanical or chemical alteration of TrPs; however, the two most common
techniques for treating a muscle pain include the spray-and-stretch tech-
nique and TrP injections.
76 FRICTON
With the spray-and-stretch technique, an application of a vapocoolant

spray, such as Fluori-Methane, over the muscle with simultaneous passive
stretching can provide immediate reduction of pain, although lasting relief
requires a full management program [3]. The technique involves directing
a ne stream of vapocoolant spray from the nely calibrated nozzle toward
the skin directly overlying the muscle with the TrP. A few sweeps of the
spray is passed over the TrP and zone of reference before adding sucient
manual stretch to the muscle to elicit pain and discomfort. The muscle is put
on a progressively increasing passive stretch while the jet stream of spray is
directed at an acute angle 30 to 50 cm (11.5 feet) away. It is applied in one
direction from the TrP toward its reference zone in slow even sweeps over
adjacent parallel areas, at a rate of about 10 cm per second. This sequence
can be repeated up to four times if the clinician warms the muscle with his or
her hand or warm moist packs to prevent overcooling after each sequence.
Frosting the skin and excessive sweeps should be avoided, because they
may reduce the underlying skeletal muscle temperature, which tends to ag-
gravate TrPs. The range of passive and active motion can be tested before
and after spraying as an indication of responsiveness to therapy. Failure to
reduce TrPs with spray and stretch may be due to (1) inability to secure
full muscle length because of bone or joint abnormalities, muscle contrac-
ture, or the patient avoiding voluntary relaxation; (2) incorrect spray tech-
nique; or (3) failure to reduce perpetuating factors. If spray and stretch
fails with repeated trials, direct needling with TrP injections may be eective.
TrP muscle injections also have been shown to reduce pain, increase range
of motion, increase exercise tolerance, and increase circulation of muscles
[4,5,13]. The pain relief may last from the duration of the anesthetic to
many months, depending on the chronicity and severity of TrPs, and the de-
gree of reducing perpetuating factors. Because the critical factor in relief is the
mechanical disruption of the TrP by the needle, precision in needling the exact
TrP and the intensity of pain during needling seem to be the major factors in
TrP inactivation [14]. Generally, TrP injections with local anesthetic are more
eective and comfortable than are dry needling or injecting other substances
(eg, saline), although acupuncture may be helpful for patients who have
chronic TrPs in multiple muscles. The eect of needling can be complemented
with local anesthetics in concentrations that are less than those required for
a nerve conduction block. This can markedly lengthen the relative refractory
period of peripheral nerves and limit the maximum frequency of impulse con-
duction. Local anesthetics can be chosen for their duration, safety, and ver-
satility; local anesthetics without vasoconstrictors are suggested.
Pharmacotherapy
Pharmacotherapy is a useful adjunct to initial treatment of muscle pain.
The most commonly used medications for pain are classied as nonnarcotic
analgesics (nonsteroidal anti-inammatory drugs [NSAIDs]), narcotic
analgesics, muscle relaxants, tranquilizers, sedatives, and antidepressants.

Analgesics are used to allay pain, muscle relaxants and tranquilizers for anx-
iety, fear, and muscle tension; sedatives for enhancing sleep; and antidepres-
sants for pain, depression, and enhancing sleep [15].
Randomized clinical trials on NSAIDs, such as ibuprofen or piroxicam,
suggest that for myalgia, their short-term use for analgesic or anti-inamma-
tory eects can be eective as a supplement to overall management.
Chronic, long-term use is cautioned against because of the long-term sys-
temic and gastrointestinal eects; however, cyclooxygenase-2 inhibitors
may prove to be safer NSAIDs for long-term use with less gastrointestinal
toxicity. If some therapeutic result is not apparent after 7 to 10 days or if
the patient develops any side eects, especially gastrointestinal symptoms,
the medication should be discontinued.
For muscle pain, especially with stress and sleep disturbance, benzodiaz-
epines, including diazepam and clonazepam, are eective [1]. Experience
suggests that these are best used before bedtime to minimize sedation while
awake. Cyclobenzaprine also was shown, in clinical trials of myalgia, to be
ecacious in reducing pain and improving sleep [29,30]; it can be considered
when a benzodiazepine has side eects. These medications, with or without
NSAIDs, also can be considered for a 2- to 4-week trial with minimal habit-
ual potential; however, long-term use has not been tested adequately.
Research on medications for masticatory myalgia, especially in patients
with sleep disturbances, indicates that tricyclic antidepressants, such as am-
itriptyline/Elavil, have a signicant impact on sleep disturbances, anxiety,
and pain. As such, these medications can be used on a long-term basis in
the appropriate case [31]. The side eects with amitriptyline can be signi-
cant, however, nortriptyline can be considered an analogous medication
with fewer side eects. Typically, the dosage for either of these medications
in patients who do not have depression is in the range of 25 to 75 mg at
bedtime. The use of selective serotonin reuptake inhibitors has been sug-
gested for depression and pain, but they may have the common side eect
of increasing oral habits, muscle tension and potentially aggravating the
pain.
For chronic pain conditions that are resistant to interventions, opioids
can be considered. Tramadol has been shown to be eective in bromyalgia;
however, no randomized, controlled trial has evaluated the appropriateness
of opioids in the long-term treatment of chronic orofacial pain. Because of
their side eects, including constipation, sedation, potential for dose escala-
tion, and the unknown eects with long-term use, chronic opioid use is
indicated mainly for patients who have chronic intractable severe pain con-
ditions that are refractory to rehabilitation treatments.
Despite the advantages of medications for pain disorders, there is an op-
portunity for problems to occur as a result of their misuse. These problems
include chemical dependency, behavioral reinforcement of continuing pain,
inhibition of endogenous pain relief mechanisms, rebound pain, side eects,
78 FRICTON
and adverse eects from the use of polypharmaceuticals. For this reason,
medication should be used with proper caution.
Control of contributing factors

One of the common causes of a lack of success in managing masticatory
myalgia is failure to recognize and control contributing factors that may
perpetuate muscle restriction and tension. Postural contributing factors,
whether behavioral or biologic, perpetuate muscle pain if not corrected.
In general, a muscle is more predisposed to developing problems if it is
held in sustained contraction in the normal position, and, especially, if it
is in an abnormally shortened position. Such a situation exists with struc-
tural skeletal problems, such as loss of posterior teeth, an excessive lordosis
of the cervical spine, a unilateral short leg, or a small hemipelvis [6]. An oc-
clusal imbalance can be corrected short term with an occlusal stabilization
splint, also termed a at plane or full coverage splint. Other postural factors
that can be corrected include a foot lift for a unilateral leg length discrep-
ancy, a pelvic lift for a small hemipelvis, and proper height of arm rests
in chairs for short upper arms.
Behavioral factors that cause sustained muscle tension also can occur
with habits such as cradling a phone between the head and shoulder; a la-
borer lifting at the waist with lumbar strain; a student studying with the
head forward for hours at a time; or bruxism, clenching, gum-chewing, or
other oral parafunctional habits. Correcting poor habits through education
and long-term reinforcement is essential in preventing pain from returning.
Biofeedback, meditation, hypnosis, stress management counseling, psycho-
therapy, antianxiety medications, antidepressants, and even placebos have
been reported to be eective in reducing contributing factors to masticatory
myalgia [11,26,3234]. Many of these treatments are directed toward reduc-
ing muscle tensionproducing habits, such as bruxism or bracing of muscles.
Teaching control of habits is a dicult process because of the relationship
that muscle tension may have with psychosocial factors. Simply telling a pa-
tient to stop the habits may be helpful with some, whereas with others it may
result in noncompliance, failure, and frustration. An integrated approach
that involves education, increased awareness, and other treatments, such
as behavior modication, biofeedback, hypnosis, or drug therapy, may
prove to be more successful.
Pain clinic team management

Although each clinician may have limited success in managing the
whole patient alone, the assumption behind a team approach is that it
is vital to address dierent aspects of the problem with dierent specialists
to enhance the overall potential for success [1618]. Although these pro-
grams provide a broader framework for treating the complex patient, they
have added another dimension to the skills that are needed by the clinician:
working as part of a coordinated team. Failure to integrate care adequately
may result in poor communication, fragmented care, distrustful relation-
ships, and, eventually confusion and failure in management. Team coordi-
nation can be facilitated by a well-dened evaluation and management
system that clearly integrates team members. Fig. 4 describes a dened
patient ow from evaluation to assessment to treatment and follow-up.
A prerequisite to a team approach is an inclusive medical model and con-
ceptual framework that places the physical, behavioral, and psychosocial as-
pects of illness on an equal and integrated basis [19,35]. With an inclusive
theory of human systems and their relationship to illness, a patient can be
assessed as a whole person by dierent clinicians from diverse backgrounds.
Although each clinician understands a dierent part of the patients prob-
lem, s/he can integrate them with other clinicians perspectives and see
how each part is interrelated in the whole patient. Each contributing identi-
ed factor becomes part of the problem list to be addressed in the treatment
plan by all clinicians. In the process, the synergism of each factor in the eti-
ology of the disorder can become apparent to clinicians. For example, social
stressors can lead to anxiety, anxiety can lead to poor posture and muscle
tension, the poor posture and muscle tension can lead to myofascial pain
History, exam, order

Visit 1 tests, imaging, and other
Initial Evaluation
consults, provide self
care
Visit 2 Review test results, evaluation with

Comprehensive physical therapist and health psychologist,
Assessment review effects of self care and other
consults, and discuss diagnosis,
contributing factors, and treatment
plan
2 or more Treatment Program Myotherapy, exercises (posture,

visits as 2 hour visits every stretching, relaxation), intra-oral
needed 2-3 weeks for 2- 3 splint, anti-inflammatory and/or
months muscle relaxants, cognitive-
behavioral therapy to address
contributing factors and trigger point
injections as needed.
As needed Continue exercises, splint at night,

Follow-up and change in contributing factors.
(Every 2 to 3 months
as needed)
Fig. 4. Patient ow from evaluation to assessment to treatment of masticatory myalgia using

a team approach includes many components. The key to successful management lies in match-
ing the patients needs with the unique combination of active treatment, education on contrib-
uting factors, and self-care that is appropriate for that patient.
80 FRICTON
syndrome, the pain contributes to more anxiety, and a cycle continues. Like-
wise, a reduction of each factor works synergistically to improve the whole
problem. Treatment of only one factor may improve the problem, but relief
may be partial or temporary. Treatment of all factors simultaneously can
have a cumulative eect that is greater than the eects of treating each
factor individually.
The problem list for a patient who has a specic chronic illness includes
a physical diagnosis and a list of contributing factors. In establishing the
problem list, the clinician needs to determine if the patient is complex and
requires a team approach. Recommended criteria for determining complex-
ity include any one of the following: multiple diagnoses, persistent pain lon-
ger than 6 months in duration, signicant emotional problems (depression,
anxiety), frequent use of health care services or medication, daily oral par-
afunctional habits, and signicant lifestyle disturbances. The use of a screen-
ing instrument, such as research diagnostic criteria for temporomandibular
disorders, the McGill Pain Questionnaire, or the Multidimensional Inven-
tory, can readily elicit the degree of complexity of a case at initial evaluation
[1,3638]. The more complex the case, the greater is the need for a team ap-
proach. The decision to use a team must be made at the time of evaluation
and not part way through a failing singular treatment plan. If a team is
needed, the broad understanding of the patient is used to design a long-
term management program that treats the physical diagnosis and helps to
reduce these contributing factors.
The primary goals of the program include reducing the symptoms and
their negative eects while helping the patient return to normal function
without the need for future health care. The patient rst participates in
an educational session with each clinician to learn about the diagnoses
and contributing factors, why it is necessary to change these factors, and
how to do it. The dentist or physician is responsible for establishing the
physical diagnosis, providing short-term medical or dental care, and mon-
itoring medication and patient progress. The health psychologist is respon-
sible for providing instruction about contributing factors; diagnosing,
managing, or referring for primary psychologic disturbances; and estab-
lishing a program to support the patient and family in making changes.
The physical therapist is responsible for evaluating musculoskeletal prob-
lems, providing support, instruction, and a management program on spe-
cically assigned and common contributing factors, such as an exercise and
posture program. Depending on the therapists background and the pa-
tients needs, this person also may provide special care, such as physical
therapy modalities or occupational therapy. Each clinician also is respon-
sible for establishing a trusting, supportive relationship with the patient
while rearming the self-care philosophy of the program, reinforcing
change, and assuring compliance. The patient is viewed as responsible
for making the changes (see Table 1). The team meets weekly to review
current patient progress and discuss new patients.
Summary
Goals of treatment of masticatory myalgia include reducing or eliminating
pain, restoring normal jaw function, reducing the need for future health care,
and restoring normal lifestyle functioning. The short-term strategy is to re-
store the muscle to normal length, posture, and full joint range of motion
with exercises. The long-term strategy includes reducing the symptoms
through muscle rehabilitation while helping the patient to reduce contributing
factors, muscle tension and strain, and return to normal function without the
need for future health care.
Recent-onset cases often can be managed with palliative self-care strategies
that are designed to protect the muscles and encourage healing. Simple cases
with minimal behavioral and psychosocial involvement can be managed by
a single clinician with self-care, exercises, and a stabilization splint. Complex
patients can be managed most eectively within an interdisciplinary pain clinic
setting that uses a team of clinicians to address dierent aspects of the problem
in a concerted fashion. Behavioral and psychosocial evaluations should be
conducted on all patients who have persistent pain to determine complexity
and contributing factors.
To improve outcomes, it is important to match the level of complexity of
the management program with the complexity of the patients, and to use
a pain clinic team approach to facilitate success in complex patients. Using
clinical paradigms of self-care, education, and self-responsibility in care
enhances long-term outcomes and maintains positive relationships between
the patient and clinician.
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Dent Clin N Am 51 (2007) 85103
Joint Intracapsular Disorders:

Diagnostic and Nonsurgical
Management Considerations
Jerey P. Okeson, DMD
Department of Oral Health Science, Orofacial Pain Program, D-530 University of Kentucky
College of Dentistry, Lexington, KY 40536-0297, USA
Temporomandibular disorders (TMD) refer to a large group of musculo-

skeletal disorders that originate from the masticatory structures [1]. There
are two broad types of TMD: those primarily involving the muscles and
those primarily involving the temporomandibular joints. Muscle disorders
are far more common than intracapsular disorders. This article focuses on
the intracapsular disorders and is limited to the most common types encoun-
tered in the dental practice. The article begins with a brief review of normal
temporomandibular joint (TMJ) anatomy and function followed by a de-
scription of the common types of disorders known as internal derange-
ments. Nonsurgical management is suggested based on the long-term
scientic documentation. This article represents a brief review of these con-
ditions. Other references are suggested for more in depth information [13].
Normal function of the temporomandibular joint

For clinicians to eectively manage dysfunction of the temporomandib-
ular joint, they must have a sound understanding of normal joint function
because the treatment goal for a patient with dysfunction is to re-establish
normal function. A clinician cannot manage a disorder without a sound un-
derstanding of order.
The temporomandibular joint represents the articulation of the mandible
to the temporal bone of the cranium (Fig. 1). The bony components of the
joint are separated by a structure composed of dense brous connective tis-
sue called the articular disc. Like any mobile joint, the integrity and
86 OKESON
Fig. 1. (A) Lateral view of the temporomandibular joint. (B) Diagram revealing the following
anatomic components: ACL, anterior capsular ligament; AS, articular surface; IC, inferior joint
cavity; ILP, inferior lateral pterygoid muscle; IRL, inferior retrodiscal lamina; RT, retrodiscal
tissues; SC superior joint cavity; SLP, superior and lateral pterygoid muscle; SRL, superior ret-
rodiscal lamina. The lateral collateral discal ligament has not been drawn. (From Okeson JP.
Management of temporomandibular disorders and occlusion. 5th edition. St. Louis (MO):
C.V. Mosby Publishing; 2003. p. 10; with permission.)
limitations of the joint are maintained by ligaments. Ligaments are com-

posed of collagenous bers that have specic lengths. Ligaments do not ac-
tively participate in normal function of the joint; rather, they act as guide
wires to restrict certain movements (border movements) while allowing
other movements (functional movements). If joint movements consistently
function against ligaments, the length of the ligaments can become altered.
Ligaments have a poor ability to stretch, and therefore, when this occurs,
they often elongate. This elongation creates a change in joint biomechanics
and can lead to certain clinical changes discussed in this article.
Careful examination of the condyle and disc reveals that the disc is at-
tached to the condyle medially and laterally by the discal collateral liga-
ments (Fig. 2). These ligaments allow rotation of the disc across the
articular surface of the condyle in an anterior and posterior direction while
restricting medial and lateral movements. The range of anterior and poste-
rior rotation of the disc is also restricted by ligaments. The inferior retrodis-
cal lamina limits anterior rotation of the disc on the condyle, whereas the
anterior capsular ligament limits posterior rotation of the disc (Fig. 1).
The morphology of the disc is extremely important. It is thinnest in the
intermediate zone, thicker in the anterior border, and thickest in the poste-
rior border. The condyle articulates on the intermediate zone of the disc and
JOINT INTRACAPSULAR DISORDERS 87
Fig. 2. Anterior view of the temporomandibular joint revealing the following anatomic compo-
nents: AD, articular disc; CL, capsular ligament; IC, inferior joint cavity; LDL, lateral discal
ligament; MDL, medial discal ligament; SC, superior joint cavity. (From Okeson JP. Manage-
ment of temporomandibular disorders and occlusion. 5th edition. St. Louis (MO): C.V. Mosby
Publishing; 2003. p. 14; with permission.)
is maintained in this position by constant interarticular pressure provided by

the elevator muscles (masseter, temporalis, and medial pterygoid). Although
the pressure between the condyle, disc, and fossa can vary according to the
activity of the elevator muscles, some pressure is maintained to prevent sep-
aration of the articular surfaces. If contact between the articular surfaces is
lost, a condition of dislocation exists (dislocation means separation of the
articular surfaces).
Posterior to the disc are the retrodiscal tissues. These tissues are highly
vascularized and well innervated. Anterior to the condyle-disc complex
are the superior and inferior lateral pterygoid muscles. The inferior ptery-
goid muscle inserts on the neck of the condyle, whereas the superior lateral
pterygoid muscle inserts on the neck of the condyle and the articular disc
(Fig. 1). The inferior lateral pterygoid is active with the depressing muscles
(mouth opening), and the superior lateral pterygoid muscle has been shown
to be active in conjunction with the elevator muscles (mouth closing) [4,5].
The superior lateral pterygoid muscle seems to be a stabilizing muscle for
the condyledisc complex, especially during unilateral chewing.
When the condyledisc complex translates down the articular eminence
(ie, the mouth opening), the disc rotates posteriorly on the condyle
(Fig. 3). The superior surface of the retrodiscal tissues is unlike any other
structure in the joint. The superior retrodiscal lamina is composed of loose
connective tissue and elastin bers that allow the condyledisc complex to
translate forward without damage to the retrodiscal tissues. In the closed
88 OKESON
Fig. 3. Normal functional movement of the condyle and disc during the full range of opening
and closing. The disc is rotated posteriorly on the condyle as the condyle is translated out of the
fossa. The closing movement is the opposite of opening. (From Okeson JP. Management of tem-
poromandibular disorders and occlusion. 5th edition. St. Louis (MO): C.V. Mosby Publishing;
2003. p. 29; with permission.)
mouth position, the superior retrodiscal tissues are passive and have little in-
uence on disc position. During full mouth opening, the superior retrodiscal
lamina is fully stretched and produces a posterior, retractive force on the
disc (Fig. 3). This is the only structure in the temporomandibular joint ca-
pable of providing a retractive force on the articular disc.
During opening and closing, the disc and condyle move together, not be-
cause of ligamentous attachments, but because of two fundamental features:
the morphology of the disc and interarticular pressure (pressure between the
articular surfaces). Because some degree of interarticular pressure is always
present, the condyle maintains itself on the thinnest intermediate zone of the
disc. The thicker anterior and posterior borders of the disc force it to trans-
late with the condyle during mouth opening and closing. It is the discs mor-
phology, therefore, that requires it to move with the condyle. If there is an
alteration in interarticular pressure or a change in the morphology of the
disc, condyledisc movement can be altered. This begins the biomechanical

changes associated with internal derangements.
Intracapsular disorders of the temporomandibular joint

Once change occurs in the structure of the condyledisc complex, normal
biomechanics can be altered. This alteration results in specic clinical signs
and symptoms. It is by these signs and symptoms that a classication of dis-
orders can be developed. Intracapsular disorders fall into one of two broad
types: derangements of the condyledisc complex and structural incompat-
ibility of the articular surfaces [2]. Because of the brevity of this article, only
derangements of the condyledisc complex are discussed. These conditions
include disc displacements with reduction and disc dislocations without
reduction. In this section each category is described according to etiology,
anamnestic, or history ndings and clinical characteristics.
Disc displacement with reduction

Derangements of the condyledisc complex arise from breakdown of the
normal rotational movement of the disc on the condyle. This loss of normal
disc movement can occur when there is elongation of the discal collateral lig-
aments and the inferior retrodiscal lamina. If the inferior retrodiscal lamina
and the discal collateral ligament are elongated, the disc can be positioned
more anteriorly by pull of the superior lateral pterygoid muscle. If this an-
terior pull is constant, a thinning of the posterior border of the disc may al-
low the disc to be displaced in a more anterior position (Fig. 4, position 1).
With the condyle resting on a more posterior portion of the disc or retrodis-
cal tissues, an abnormal translatory shift of the condyle over the posterior
border of the disc can occur during opening. Associated with the abnormal
condyledisc movement is a click that may be initially felt just during open-
ing (single click) (Fig. 4, position 3) but later may be felt during opening and
closing of the mouth (reciprocal clicking) (Fig. 4, position 8).
Etiology
The most common etiologic factor associated with breakdown of the con-
dyledisc complex is trauma. This may result from macrotrauma or micro-
trauma. Macrotrauma represents a single, often sudden, episode of trauma,
such as a blow to the jaw [617]. Open mouth macrotrauma commonly pro-
duces elongation of the ligaments, whereas closed mouth trauma is more of-
ten associated with impact loading of the articular surfaces. Microtrauma is
a produced by mild, frequent forces over a long period. Chronic muscle hy-
peractivity, such as bruxism, is an example of microtrauma. Although not
well documented, chronic muscle hyperactivity may contribute to internal
derangement disorders when signicant orthopedic instability is present [2].
90 OKESON
Fig. 4. Disc displacement (dislocation) with reduction. In position 1, the posterior border of the
disc has been thinned, allowing activity of the superior lateral pterygoid to dislocate the disc
anteriorly (and medially). Between positions 3 and 4, a click is felt as the condyle moves across
the posterior border of the disc. Normal condyledisc function occurs during the remaining
opening and closing movement until the closed joint position is approached. A second click
is heard as the condyle moves from the intermediate zone over the posterior border of the
disc (between positions 8 and 1). (From Okeson JP. Management of temporomandibular disor-
ders and occlusion. 5th edition. St. Louis (MO): C.V. Mosby Publishing; 2003. p. 213; with
permission.)
History
It is common for a history of trauma to be associated with the onset of
joint sounds. There may or may not be pain accompanying the disc displace-
ment with reduction. If pain is present, it is intracapsular and associated
with the dysfunction (the click).
Clinical characteristics
Examination reveals joint sounds during mouth opening and often dur-
ing mouth closure. Disc displacement is characterized by a normal range
of jaw movement during opening and eccentric movements. Any limitation
is due to pain and not to a true structural dysfunction. When reciprocal
clicking is present, the two clicks normally occur at dierent degrees of

mouth opening, with the closing click usually occurring near the intercuspal
position. Pain, if present, is directly related to joint function.
If the inferior retrodiscal lamina and discal collateral ligaments become
further elongated and the posterior border of the disc suciently thinned,
the disc can slip or be forced completely through the discal space. Because
the disc and condyle no longer articulate, this condition is referred to as
a disc dislocation (Fig. 4). If the patient can manipulate the jaw to repo-
sition the condyle over the posterior border of the disc, the disc is said to be
reduced. This represents a progression of the disc movement and may be
accompanied by the patient report of joint catches and getting stuck. The
patients may describe having to move the jaw around a little to get it back
to functioning normally. The catching may or may not be painful, but if
pain is present it is directly associated with the dysfunctional symptoms.
Disc dislocation without reduction

As the elasticity of the superior retrodiscal lamina is lost or the disc un-
dergoes morphologic change, recapturing of the disc becomes more dicult.
When the disc is not reduced, the forward translation of the condyle forces
the disc further anteriorly (Fig. 5). This is clinically called a closed lock
because the disc dislocation does not allow full mouth opening.
History
Most patients who have a history of disc dislocation without reduction
know precisely when the dislocation occurred. They can readily relate it to
an event such as biting into an apple or waking up with the condition. They
report that the jaw is locked closed so that normal mouth opening cannot
be achieved. Pain is commonly associated with dislocation without reduction.
When pain is present, it usually accompanies trying to open beyond the point
of joint restriction. The history also reveals that clicking occurred before the
onset of locking but not since the disc dislocation has occurred.
Clinical characteristics
The range of mouth opening is commonly between 25 and 30 mm, and
the mandible often deects toward the involved joint during maximum
opening. At the maximum point of opening, there is a hard end feel. In other
words, if mild, steady, downward forward pressure is applied to the lower
incisors, there is no increase in mouth opening. Eccentric movement is rel-
atively normal to the ipsilateral side but restricted to the contralateral
side. Loading the joint with bilateral manual manipulation is often painful
because the condyle is seated on the retrodiscal tissues.
Nonsurgical management of intracapsular disorders

The correct management of TMJ intracapsular disorders is predicated on
two factors: making a correct diagnosis and understanding the natural
92 OKESON
Fig. 5. Disc dislocation without reduction (closed lock). The disc is dislocated anterior to the
condyle and never assumes a normal relationship during opening. This condition limits the dis-
tance the condyle can translate forward, resulting in limited mouth opening. (From Okeson JP.
Management of temporomandibular disorders and occlusion. 5th edition. St. Louis (MO): C.V.
Mosby Publishing; 2003. p. 214; with permission.)
course of the disorder. Each of the categories of internal derangements rep-

resents a clinical condition that is treated in a particular manner. An incor-
rect diagnosis leads to mismanagement and treatment failure.
Successful management of intracapsular disorders is also based on the cli-
nicians understanding of the natural course of the disorder. Although the
sequence of internal derangements is often clinically evident, it does not ac-
count for the outcome of all intracapsular disorders. The presence of
chronic, unchanging, asymptomatic joint sounds suggests that intracapsular
disorders are not always progressive. Epidemiologic studies reveal that
asymptomatic joint sounds are common [1822]. This poses an interesting
question: If all joint sounds are not progressive, which sounds should be
treated? It is my opinion that only joint sounds associated with pain should
be considered for treatment provided that the pain is intracapsular in origin.
In other words, patients who present with extracapsular muscle pain and
a painless clicking joint should not be managed for the intracapsular
disorder. Doing so leads to treatment failure because it does not address the
source of the pain. Most painless joint sounds do not seem to lead to any
major progressive disorders [2229].
The management of disc displacement with reduction and disc disloca-
tion without reduction is discussed separately because data suggest they
should be managed dierently.

Denitive treatment for disc displacement with reduction (and disc dislo-
cation with reduction) is to re-establish a normal condyledisc relationship.
Although this may sound relatively easy, it has not proven to be so. During
the past 30 years, the dental professions attitude toward management of in-
tracapsular disc derangements has changed greatly. In the early 1970s, Far-
rar [30] introduced the anterior positioning appliance. This appliance
provides an occlusal relationship that requires the mandible to be main-
tained in a forward position (Fig. 6). The position selected is one that places
the mandible in the least protruded position that re-establishes a more nor-
mal condyledisc relationship. This is usually achieved clinically by moni-
toring the clicking joint. Although eliminating the click does not always
Fig. 6. The anterior positioning appliance. (A) The anterior positioning appliance causes the
mandible to assume a forward position, creating a more favorable condyledisc relationship.
(B) During normal closure, the mandibular anterior teeth contact in the retrusive guiding
ramp provided by the maxillary appliance. (C) As the mandible rises into occlusion, the
ramp causes it to shift forward into the desired position that eliminates the disc derangement
disorder. At the desired forward position, all teeth contact to maintain arch stability. (From
Okeson JP. Management of temporomandibular disorders and occlusion. 5th edition. St. Louis
(MO): C.V. Mosby Publishing; 2003. p. 441; with permission.)
94 OKESON
denote successful reduction of the disc [31,32], it is a good clinical reference

point for beginning therapy.
The idea behind the anterior positioning appliance was to position the
condyle back on the disc (ie, to recapture the disc). It was originally sug-
gested that this appliance be worn 24 h/d for as long as 3 to 6 months. Al-
though this appliance is helpful in managing certain disc derangement
disorders, its use has changed considerably due to results of recent studies.
It was quickly discovered that the anterior positioning appliance was use-
ful in reducing painful joint symptoms [33,34]. When this appliance success-
fully reduced symptoms, a major treatment question was asked: Whats
next? Some clinicians believed that the mandible needed to be permanently
maintained in this forward position [35,36]. Dental procedures were sug-
gested to create an occlusal condition that maintained the mandible in
this therapeutic relationship. Accomplishing this task was never a simple
dental procedure [37]. Others felt that once the discal ligaments repaired,
the mandible should be returned to its normal position in the fossa (the mus-
culoskeletally stable position), and the disc would remain in proper position
(recaptured). Although one approach is more conservative than the other,
neither is supported by long-term data.
In early short-term studies [7,33,34,3843], the anterior positioning appli-
ance proved to be much more eective in reducing intracapsular symptoms
than the more traditional stabilization appliance. This led to the belief that
returning the disc to its proper relationship with the condyle was an essential
part of treatment. The greatest insight regarding the appropriateness of
a treatment modality is gained from long-term studies. Forty patients
with various derangements of the condyledisc complex were evaluated
2.5 years after anterior positioning therapy and a step-back procedure
[38]. None received occlusal alterations. It was reported that 66% of the pa-
tients still had joint sounds, but only 25% were still experiencing pain prob-
lems. If the criteria for success in this study were the elimination of pain and
joint sounds, then success was achieved in only 28%. Other long-term stud-
ies [7,44] have reported similar ndings. If the presence of asymptomatic
joint sounds is not a criterion for failure, then the success rate for anterior
positioning appliances rises to 75%. The issue that must be addressed, there-
fore, is the clinical signicance of asymptomatic joint sounds.
Joint sounds are common in the general population. In many cases
[2229], it seems that they are not related to pain or decreased joint mobility.
If all clicking joints progressed to more serious disorders, then this would be
a good indication to treat every joint that clicked. The presence of unchang-
ing joint sounds over time indicates that the structures involved can adapt to
less than optimum functional relationships.
Long-term studies reveal that anterior positioning appliances are not as
eective as once thought. They seem to be helpful in reducing pain in
75% of the patients, but joint sounds seem to be much more resistant to
therapy, and their persistence does not always indicate a progressive
disorder. These studies provide insight into how the joint responds to ante-
rior positioning therapy. In many patients, advancing the mandible forward
temporarily prevents the condyle from articulating with the highly vascular-
ized, well innervated, retrodiscal tissues. This is the likely explanation for an
almost immediate reduction of intracapsular pain. During the forward po-
sitioning, the retrodiscal tissues undergo adaptive and reparative changes
[4556]. These changes result in dense brosis connective tissues that can
be loaded by the condyle in the absence of pain.
Discs generally are not recaptured by anterior positioning appliances
[5759]. Instead, as the condyle returns to the fossa, it moves posteriorly to
articulate on the adapted retrodiscal tissues. If these tissues have adequately
adapted, loading occurs without pain. The condyle functions on the newly
adapted retrodiscal tissues, although the disc is still anteriorly displaced.
The result is a painless joint that may continue to click with condylar move-
ment (Fig. 7). At one time the dental profession believed that the presence of
joint sounds indicated treatment failure. Long-term follow-up studies have
given the profession new insight regarding success and failure. We, like
our orthopedic colleagues, have learned to accept that some dysfunction
is likely to persist once joint structures have been altered. Controlling
pain while allowing joint structures to adapt seems to be the most important
role of the therapist.
A few long-term studies [36,60,61] support the concept that permanent
alteration of the occlusal condition can be successful in controlling most ma-
jor symptoms. This treatment requires extensive dental therapy, and one
must question the need when natural adaptation seems to work well for
most patients. Reconstruction of the dentition or orthodontic therapy
should be reserved for patients who present with a signicant orthopedic
instability.
The continuous use of anterior positioning appliance therapy is not with-
out consequence. A certain percentage of patients who wear these appli-
ances may develop a posterior open-bite. A posterior open-bite is likely
Fig. 7. Adaptive changes in the retrodiscal tissues. (A) An anteriorly displaced disc with the
condyle articulating on the retrodiscal tissues producing pain. (B) An anterior positioning ap-
pliance is placed in the mouth to bring the condyle forward o of the retrodiscal tissues onto the
disc. This relationship lessens the loading of the retrodiscal tissues, which decreases the pain.
(C) Once the tissues have adapted, the condyle can assume the original musculoskeletally stable
position and painless function on this new brotic tissues. A click may remain because the disc
is still displaced. (From Okeson JP. Management of temporomandibular disorders and occlu-
sion. 5th edition. St. Louis (MO): C.V. Mosby Publishing; 2003. p. 445; with permission.)
96 OKESON
the result of a reversible, myostatic contracture of the inferior lateral ptery-

goid muscle. When this condition occurs, a gradual relengthening of the
muscle can be accomplished by converting the anterior positioning appli-
ance to a stabilization appliance, which allows the condyles to assume the
musculoskeletally stable position. This can also be accomplished by slowly
decreasing use of the appliance.
The degree of myostatic contracture that develops is likely to be propor-
tional to the length of time the appliance has been worn. When these appli-
ances were rst introduced, it was suggested that they be worn 24 h/d for 3
to 6 months. With 24-hour use, the development of a posterior open bite
was common. The present philosophy is to reduce the time the appliance
is being worn to limit the adverse eects on the occlusal condition. For
most patients, full-time use is not necessary to reduce symptoms. The pa-
tient should be encouraged to wear the appliance only at night to protect
the retrodiscal tissues from heavy loading (bruxism). During the day, the pa-
tient should not wear the appliance so that the mandible can return to its
normal position. In most instances, this allows a mild loading of the retro-
discal tissue during the day, which enhances the brotic response of the ret-
rodiscal tissues. If the symptoms can be adequately controlled without
daytime use, myostatic contracture is avoided. This technique is appropriate
for most patients, but if signicant orthopedic instability exists, symptoms
may not be controlled.
If the symptoms persist with only night-time use, the patient may need to
wear the appliance more often. Daytime use may be necessary for a few
weeks. As soon as the patient becomes symptom free, the use of the appli-
ance should be gradually reduced. If reduction of use creates a return of
symptoms, then the time allowed for tissue repair has not been adequate
or orthopedic instability is present. It is best to assume that inadequate
time for tissue repair is the reason for the return of symptoms. The anterior
positioning appliance should therefore be reinstituted and more time given
for tissue adaptation.
When repeated attempts to eliminate the appliance fail to control symp-
toms, orthopedic instability should be suspected. When this occurs, the an-
terior positioning appliance should be converted to a stabilization appliance
that allows the condyle to return to the musculoskeletally stable position.
Once the condyles are in the musculoskeletally stable position the occlusal
condition should be assessed for orthopedic stability. If obvious orthopedic
instability exists, dental procedures may need to be considered. In this
authors experience, the need for dental procedures is rare.
Supportive therapies
In addition to appliance therapy, the patient should be educated about
the mechanics of the disorder and the adaptive process that is essential
for treatment. When pain is present, the patient needs to be encouraged
to decrease loading of the joint when ever possible. Softer foods, slower
chewing, and smaller bites should be promoted. The patient should be told
not to allow the joint to click whenever possible. If inammation is sus-
pected, a nonsteroidal anti-inammatory drug, such as ibuprofen (600
800 mg, three times a day), may be prescribed. Moist heat or ice can be
used if the patient nds either helpful. Active exercises are not usually help-
ful because they cause joint movements that often increase pain. Passive jaw
movements may be helpful, and distractive manipulation by a physical ther-
apist may assist in healing. These general principles are appropriate for most
intracapsular disorders.
Disc dislocation without reduction

In the case of disc displacement with reduction, the anterior positioning
appliance re-establishes the normal condyledisc relationship. Fabricating
an anterior positioning appliance for a patient who has a disc dislocation
without reduction aggravates the condition by forcing the disc further for-
ward. Patients who present with disc dislocation without reduction
(Fig. 5) need to be managed dierently.
When the condition of disc dislocation without reduction is acute, the ini-
tial therapy should include an attempt to reduce or recapture the disc by
manual manipulation. This manipulation is most successful with patients
who are experiencing their rst episode of locking. In these patients, there
is a great likelihood that tissues are healthy and with minimal morphologic
changes. Patients who have a long history of locking are likely to present
with discs and ligaments that have undergone changes that will not allow re-
duction of the disc. As a general rule, when patients report a history of being
locked for a week or less, manipulation is often successful. In patients who
have a longer history, success begins to decrease rapidly.
The success of manual manipulation for the reduction of a dislocated disc
depends on three factors. The rst factor is the level of activity in the supe-
rior lateral pterygoid muscle. This muscle must be relaxed to permit success-
ful reduction. If it remains active because of pain, it may need to be injected
with local anesthetic before any attempt to reduce the disc. Second, the disc
space must be increased so the disc can be repositioned on the condyle.
When increased activity of the elevator muscles is present, the interarticular
pressure is increased, making it more dicult to reduce the disc. The patient
needs to be encouraged to relax and avoid forcefully closing the mouth.
Third, the condyle must be in the maximum forward translatory position.
The only structure that can produce a posterior or retractive force on the
disc is the superior retrodiscal lamina, and if this tissue is to be eective,
the condyle must be in the most forward protrusive position.
The rst attempt to reduce the disc should begin by having the patient
attempt to self-reduce the dislocation. With the teeth slightly separated,
the patient is asked to move the mandible to the contralateral side of the dis-
location as far as possible. From this position the mouth is opened maxi-
mally. If this is not successful at rst, the patient should attempt this
98 OKESON
several times. If the patient is unable to reduce the disc, assistance with
manual manipulation is indicated. The thumb is placed intraorally over
the mandibular second molar on the aected side. The ngers are placed
on the inferior border of the mandible anterior to the thumb position.
Firm but controlled downward force is exerted on the molar at the same
time that upward force is placed by the ngers on the outer inferior boarder
of the mandible in the anterior region. The opposite hand helps stabilize the
cranium above the joint that is being distracted. While the joint is being dis-
tracted, the patient is asked to assist by slowly protruding the mandible,
which translates the condyle downward and forward out of the fossa. It
may be helpful to bring the mandible to the contralateral side during the dis-
traction procedure because the disc is likely to be dislocated anteriorly and
medially, and a contralateral movement moves the condyle into it better.
Once the full range of laterotrusive excursion has been reached, the pa-
tient is asked to relax for 20 to 30 seconds while constant distractive force
is applied to the joint. The clinician needs to be sure that unusual heavy
forces are not placed on the uninvolved joint. Always ask the patient if he
or she is feeling any discomfort in the uninvolved joint. If there is discom-
fort, the procedure should be immediately stopped and begun again with
the proper directional force placed. A correctly performed manual manipu-
lation to distract a TMJ should not jeopardize the healthy joint.
Once the distractive force has been applied for 20 to 30 seconds, the force
is discontinued, and the ngers are removed from the mouth. The patient is
asked to lightly close the mouth to the incisal end-to-end position on the an-
terior teeth. The patient is asked to relax for a few seconds and then to open
wide and immediately return to this anterior position (not maximum inter-
cuspation). If the disc has been successfully reduced, the patient should be
able to open to the full range (no restrictions). When this occurs, the disc
has likely been recaptured, and an anterior positioning appliance is immedi-
ately placed to prevent clenching on the posterior teeth, which would likely
redislocate the disc. At this point, the patient has a normal condyledisc re-
lationship and should be managed in the same manner as discussed for the
patient who has a disc dislocation with reduction, with one exception.
When an acute disc dislocation has been reduced, it is advisable to have
the patient wear the anterior positioning appliance continuously for the rst
2 to 4 days before beginning only night-time use. The rationale for this is
that the dislocated disc may have become distorted during the dislocation,
which may allow it to redislocated more easily. Maintaining the anterior po-
sitioning appliance in place for a few days may help the disc reassume its
more normal shape (thinnest in the intermediate band and thicker anterior
and posterior). If the normal morphology is present, the disc is more likely
to be maintained its normal position. If this disc has permanently lost its
normal morphology, it is dicult to maintain its position. This is why man-
ual manipulations for disc dislocations are attempted only in acute condi-
tions when the likelihood of normal disc morphology exists.
If the disc is not successfully reduced, a second and possibly a third at-
tempt can be attempted. Failure to reduce the disc may indicate a dysfunc-
tional superior retrodiscal lamina or a general loss of disc morphology.
Once these tissues have changed, the disc dislocation is most often
permanent.
If the disc is permanently dislocated, what types of treatments are indi-
cated? This question has been asked for many years. At one time it was
felt that the disc needed to be in its proper position for health to exist.
Therefore, when the disc could not be restored to proper position, a surgical
repair of the joint seemed to be necessary. Over years of studying this con-
dition, we have learned that surgery may not be needed for most patients.
Studies [6273] have revealed that over time many patients achieve relatively
normal joint function even with the disc permanently dislocated. With these
studies in mind, it would seem appropriate to follow a more conservative ap-
proach that would encourage adaptation of the retrodiscal tissues. Patients
who have permanent disc dislocation should be given a stabilization appli-
ance that reduces forces to the retrodiscal tissues (ie, decrease bruxism) [74].
Supportive therapy
Supportive therapy for a permanent disc dislocation should begin with
educating the patient about the condition. Because of the restricted range
of mouth opening, many patients try to force their mouth to open wider.
If this is attempted too strongly, it aggravates the intracapsular tissues, pro-
ducing more pain. Patients should be encouraged not to open too wide es-
pecially immediately after the dislocation. With time and tissue adaptation,
they will be able to return to a more normal range of movement (usually O
40 mm) [6369,71]. Gentle, controlled jaw exercise may be helpful in regain-
ing mouth opening [75,76], but care should be taken to not be too aggres-
sive, which may lead to more tissue injury. The patient must be told that
this may take a year or more for full range to be attained.
The patient should be told to decrease hard biting, to avoid chewing gum,
and to avoid anything that aggravates the condition. If pain is present, heat
or ice may be used. Nonsteroidal anti-inammatory drugs are indicated for
pain and inammation. Joint distraction and phonophoresis over the joint
area may be helpful.
When a joint is not able to adapt to a dislocated disc, pain may become
a signicant symptom. This pain forces the clinician into more aggressive
approaches. Therapies that may need to be considered are arthrocentesis,
arthroscopy, and arthrotomy.
Summary
The treatment goals for managing intracapsular disorders of the tempo-
romandibular joint have changed over the past 20 years. There is no longer
an attitude that all discs must be properly positioned to maintain a healthy
100 OKESON
joint. Therapies for re-establishing disc position, for the most part, have
failed. On the other hand, patients seem to adapt to abnormal disc positions
and function relatively normally. Intracapsular disorders seem to follow
a natural course that is inuenced by many factors. Therapy does not
seem to radically change this course. However, therapy can reduce the suf-
fering that accompanies some of the stages of these disorders. It is the ther-
apists role to intervene when possible to decrease suering. Reversible
therapies are often adequate and should be attempted rst. Only when re-
versible therapies fail to adequately reduce suering should more aggressive
therapies be considered. When suering continues, re-evaluation of the clin-
ical condition is necessary to assure that more aggressive therapy eectively
alters the symptoms.
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Dent Clin N Am 51 (2007) 105127
Temporomandibular Disorders:
Associated Features
Ronald C. Auvenshine, DDS, PhDa,b,*
a
Orofacial Pain Clinic, Michael E. DeBakey VA Hospital, 7505 South Main Street,
#210, Houston, TX 77030, USA
b
The University of Texas Dental Branch-Houston, Houston, TX, USA
Temporomandibular disorder (TMD) is a collective term that encom-

passes a number of clinical problems involving the masticatory muscles or
the temporomandibular joints. These disorders have been identied as a
major cause of nondental pain in the orofacial region, and are considered
to be a subclassication of musculoskeletal disorders [1].
Orofacial pain and TMD can be associated with pathologic conditions or
with disorders related to somatic and neurologic structures, such as primary
headache disorders and neurogenic pain disorders. Primary headache disor-
ders are a group of pain disorders that originate in neuropathology and
vascular pathology. Neurogenic pain disorders are conditions resulting
from functional abnormalities within the nervous system. When patients
present to the dental oce with a chief complaint of pain or headaches, it
is vital for the practitioner to understand the cause of the complaint and
to perform a thorough examination that will lead to the correct diagnosis
and appropriate treatment. A complete understanding of the associated
medical conditions with symptomology common to TMD and orofacial
pain is necessary for a proper diagnosis.
One critical point of understanding for the clinician is the concept of
chronic versus acute pain. The International Association for the Study of
Pain has dened chronic pain as pain lasting longer than 6 months. There-
fore, acute pain refers to pain from onset to 6 months (Fig. 1). The pain path-
way has two divisions. One of the divisions travels through the midbrain, to
terminate in the posterior aspect of the lateral thalamus (the discriminative
system). The other division travels through the medial thalamus to the
* Orofacial Pain Clinic, Michael E. DeBakey VA Hospital, 7505 South Main Street,
#210, Houston, TX.
106 AUVENSHINE
Fig. 1. Time course of change from acute to chronic pain. (From Auvenshine RC. Acute vs.
chronic pain-an overview. Tex Dent J 2000;117(7):19; with permission.)
hypothalamus and limbic forebrain (the motivational/eective system). The

discriminative system allows the brain to properly locate the site and source
of pain. The motivational/eective system involves the emotional component
of painful experiences [2].
During the rst 6 months of pain, the discriminative system dominates
the motivational/eective system, allowing the patient to comprehend better
the location and duration of his/her pain. The patient can describe the pain
more accurately because the brain is better able to localize and isolate it.
However, as time progresses, expression of the motivational/eective system
gains in strength and begins to play a more dominant role in the pain expe-
rience. At 6 months, an inversion of the pain response expression occurs, in
which the motivational/eective system now dominates the pain language.
Consequently, the pain language used by the chronic pain patient is charac-
terized more by psychologic terms than descriptive terms. As the pain con-
tinues without resolution, the pain language becomes so nondescript that it
is dicult for the dental practitioner to identify the source and site of the
pain. In this situation, the words used to describe the pain can provide
only clues to diagnosis and treatment. It is vital that the practitioner be
aware of the patients history and any potential conicts or contributing
factors that may play a role in the patients pain expression [3].
When faced with a patient suering from pain, the dierentiation of acute
from chronic pain begins at the initial visit. In history taking, one of the rst
questions the practitioner must ask is, How long has this pain been present?
The most common symptoms of acute pain are headaches, jaw pain, ear-
ache, neck pain, muscle soreness, muscle tightness, and teeth pain (Box 1).
Conversely, the most common symptoms reported by the chronic pain suf-
ferer are headaches, depression, chronic fatigue, sleep disorders, decreased
productivity, feelings of inadequacy, low self-esteem, withdrawal, and
mood disorders (Box 2).
TEMPOROMANDIBULAR DISORDERS: ASSOCIATED FEATURES 107
Box 1. Symptoms related to acute TMD

Headaches
Jaw pain
Earache
Neck pain
Muscle soreness
Muscle tightness
Tooth pain
From Auvenshine RC. Acute vs. chronic painan overview. Tex Dent J
2000;117(7):19.
Comparison between the symptoms of acute and chronic TMD suggests

that the pain language and descriptions of patients who have acute pain are
more specic and somatically accurate. Their reported symptoms dene
location and pain intensity. In contrast, the pain language used by chronic
pain suerers is more vague and less descript. Their pain language becomes
wrapped in psychologic terminology, indicating the dominance of the
motivational/eective system [2].
Chronic pain continues to be poorly understood and managed. However,
research endeavors to broaden our understanding of pain and to contribute
valuable insight into pain management. For instance, it is known that nerve
signals arising from sites of tissue or nerve injury lead to long-term changes
in the central nervous system (CNS) and in the amplication and persistence
of pain. These nociceptor activityinduced, neuronal changes, known as
central sensitization (CS), have important clinical implications in the
Box 2. Symptoms related to chronic TMD

Headaches
Depression
Chronic fatigue
Sleep disorders
Decreased productivity
Feelings of inadequacy
Low self-esteem
Withdrawal
Decreased libido
From Auvenshine RC. Acute vs. chronic painan overview. Tex Dent J
2000;117(7):19.
108 AUVENSHINE
development of new approaches to the management of persistent pain and

to poorly understood conditions such as oral dysesthesia, burning mouth
syndrome, atypical facial pain/atypical odontalgia, common peripheral
nerve injury/deaerentation, and phantom tooth syndrome [4].
Historical background
Patients seek help from doctors for symptoms, which are warning signs of
impending disease. Symptoms are the expression of a patients subjective ex-
perience in his/her body. Diseases are objectively observable abnormalities
in the body. Diculties arise when the doctor can nd no objective changes
to explain the patients subjective experience. When this occurs, these symp-
toms are referred to as medically unexplained or functional [5]. Many
dierent functional syndromes have been described. In fact, each medical
specialty seems to have at least one. For rheumatologists, prominent muscle
pain and tenderness is bromyalgia (FM); for gastroenterologists, abdomi-
nal pain with altered bowel habit is irritable bowel syndrome (IBS); for
internal medicine specialists, chronic fatigue and myalgia is a postviral or
chronic fatigue syndrome (CFS) (Table 1) [5].
The existence of specic somatic syndromes is said to reect a tendency of
specialists to focus on only those symptoms pertinent to their specialty,
rather than on any real dierences among patients. Three major questions
that can be postulated are:
Table 1
Functional somatic syndromes by specialty
Specialty Syndrome
Dentistry Temporomandibular joint disorders
Atypical facial pain
Neurology Tension headache
Migraine
Ear, nose, and throat Sinusitis
Ear pain
Vertigo
Tinnitus
Allergy Multiple chemical sensitivity
Internal medicine Chronic (postviral) fatigue syndrome
Rheumatology Fibromyalgia
Gastroenterology Irritable bowel syndrome
Nonulcer dyspepsia
Gynecology Premenstrual syndrome
Chronic pelvic pain
Respiratory medicine Hyperventilation syndrome
Cardiology Atypical or noncardiac chest pain/ MVP dysautonomia
1. Do published diagnostic criteria for each specic functional syndrome

overlap in their constituent symptoms?
2. Do patients who have one functional somatic syndrome also meet symp-
tom criteria for others?
3. Are there similarities across syndromes and nonsymptom characteristics
of sex, coexisting emotional disorders, proposed causes, and prognosis
and response to treatment [5]?
Various names have been given to functional somatic syndromes, includ-
ing somatization, somatoform disorders, and medically unexplained symp-
toms. Functional somatic syndromes and their symptoms pose a major
challenge to medicine and dentistry. These syndromes have symptoms
that are common and frequently persistent, and are associated with signi-
cant distress and disability. Functional somatic syndromes are not only
common, but also clinically important, and can be a major health issue.
Most of the current thinking toward these syndromes is focused on medical
subspecialties, when, in fact, a review of the literature strongly suggests that
these syndromes have much in common. Therefore, they should have
a broader denition because several of these syndromes can be present in
the same individual. Conventional medical therapy is fairly ineective for
these patients, and results in frustrated physicians and dissatised patients
with chronic symptoms; it often leads to unnecessary expenditure of medical
resources.
Central sensitivity syndrome

In 2000, Yunus [6] reviewed the evidence for CS and functional somatic
syndromes. He compared FM-related syndromes, and coined the term
central sensitivity syndrome (CSS). He stated that CSS comprises a similar
and overlapping group of syndromes that lack demonstrable structural
pathology and are bound by a common pathway, which leads to CS
(Fig. 2). Members of this group include FM syndrome, chronic headaches,
IBS, CFS, myofascial pain syndrome, restless leg syndrome, periodic limb
movement disorder, TMD, multiple chemical sensitivity (MCS), female
urethral syndromes, interstitial cystitis, primary dysmenorrhea/functional
chronic pelvic pain, posttraumatic stress disorder, and depression [6].
Although proof of CS is lacking in some of the syndromes at this time,
Yunus included them, based on clinical presentation.
Yunus [7] rst suggested a relationship among these various syndromes in
1981. This controlled study demonstrated an association between IBS, ten-
sion type headaches, and migraine. In addition, the presence of overlapping
conditions was noted to occur in some patients, with muscle spasms being
the common binding symptom [8].
Nearly all chronic pain suerers complain of depression, despite the
current lack of direct evidence linking CS to sensory function in depression.
110 AUVENSHINE
Fig. 2. Proposed members of the CSS group, including depression. The common pathophysi-
ologic binder for the interrelated syndromes is CS. MCS, multiple chemical sensitivity; MPS,
myofascial pain syndromes; PLMD, period limb movement disorder; PTSD, posttraumatic
stress disorder; T-T headache, tension-type headache. (From Yunus MB. The concept of central
sensitivity syndromes. In: Wallace DJ, Clauw DJ, editors. Fibromyalgia & other central pain
syndromes. Philadelphia: Lippincott Williams & Wilkins. 2005. p. 40; with permission.)
In recent years, Post [9] of the National Institutes of Health has presented
arguments suggesting that depression is based on CS. This approach recog-
nizes that most cases of depression follow stressful events, primarily of a psy-
chosocial nature, which initiate various biologic processes, including gene
transcription and other neurochemical-hormonal changes. These modica-
tions lead to intracellular changes and subsequent CS [9]. When continued
exposure to stress occurs, even of less severity, there is a progressive sensi-
tization of the CNS. Neuronal hyperexcitability then becomes self-
sustained, so that, even without discernable stress, depression becomes
chronic [9]. A similar model has also been suggested for other psychiatric
diseases, such as anxiety disorders [6].
The understanding of CSS is of great value to the dental practitioner.
Therefore, emphasis should be placed on training the clinician for recogni-
tion, proper treatment, or referral of these distressing disorders. Because
these disorders are interrelated and may be expressed in the same individual,
knowledge of mutual association is vital for earlier and more accurate diag-
nosis, thus avoiding unnecessary and expensive investigations. Treatment
that is eective by clinical trials in one patient may not be eective in others,
but the more that is known about the pathophysiology of CS, the more
appropriate will be the treatment rendered and the more positive the
outcomes.
Hypothalamic-pituitary-adrenal axis
The hypothalamic-pituitary-adrenal (HPA) axis is known to play a role
in the coordinating of the bodys physiologic response to physical and emo-
tional stressors. The HPA axis exhibits a circadian rhythm related to night/
day, or sleep/awake, 24-hour cycles. Peak production of cortisol occurs in
the early morning hours and decreases steadily to its lowest level in the even-
ing. In addition to normal cortisol production, stress-induced secretion of
cortisol can be added to the supply. Regulation of the HPA axis depends
on key substances, such as hypothalamic corticotropin-releasing hormone
(CRH) acting in synergy with vasopressin. They induce the release of adre-
nocorticotropic hormone (ACTH) from the anterior pituitary. Release of
ACTH results in the production of corticosteroids from the adrenal glands
that subsequently exert negative feedback on the hippocampus, the pitui-
tary, and the hypothalamus through mineralocorticoid and glucocorticoid
receptors. Other mediators that regulate the HPA axis include serotonin,
norepinephrine, substance P, and IL-6 [10,11].
A study recently published by Ulrich-Lai [12] demonstrated a relationship
between increased nociceptor sensitivity during chronic pain and alterations
in the limbic system, and a disassociation from HPA activation. The limbic
system, which integrates behavior, is composed of the limbic forebrain, hip-
pocampus, fornix, amygdala, medial thalamus, mamillary body, hypothala-
mus, and pituitary. The intimate relationship of the limbic lobe with the
hypothalamus, and the inclusion of the neurostructures within the limbic
system, have caused many to refer to the limbic system as the visceral brain
[3]. This system has a close, anatomic, and functional relationship to the hy-
pothalamus. It is concerned intimately not only with emotional expression,
but also with the genesis of emotions. In addition to its roles in olfaction and
regulation of feeding behavior, the limbic system aects motivation and the
expression of fear and rage. It exerts control over the autonomic nervous
system by way of the pituitary gland and its target organs.
The close relationship of the limbic lobe to the hypothalamus allows it to
inuence control over the releasing factors located within the hypothalamus.
When released, these factors start a chain of hormonal events that begins
with stimulation of the pituitary gland and eventually results in a desired
eect on a target organ. For example, stimulation of the pituitary gland
causes the release of pituitary hormones that act on target glands to release
target gland hormones. Target organs are inuenced by the release of target
gland hormones, such as cortisone and aldosterone from the adrenal cortex;
testosterone, estrogen, and progesterone from the male and female gonads;
112 AUVENSHINE
thyroxine (T4) from the thyroid glands; and somatomedin from the liver.
These events continue to form a feedback loop as many of the hormones,
in turn, aect brain function. The transduction of psychologic events into
endocrine changes occurs by way of neuromodulators and neurotransmitters,
which regulate the sensitivity of neurons to the stimulation, discharge, and
conduction of nerve impulses from one neuron to another across the synaptic
clef. Many such substances have been identied in the CNS, including bio-
genic amines like dopamine, norepinephrine, and serotonin, and acetylcho-
line, histamine, gamma-aminobutyric acid, and glycine, along with steroid
and pituitary hormones and their hypothalamic and inhibiting factors [13].
Chronic pain may be considered a form of chronic stress. Patients expe-
riencing this type of pain often exhibit disturbances in the HPA axis, includ-
ing abnormal cortisol levels. Chronic pain patients report an increased
incidence of depression and anxiety, stress-related disorders that frequently
are accompanied by disturbances in the limbic system and in the HPA axis.
Despite the fact that the literature supports a strong link between chronic
pain, stress disorders, and limbic dysfunctions, the mechanisms underlying
the eects of chronic pain on the HPA axis and the limbic system are not
understood fully. The HPA axis is hyperactive during depression because
of genetic factors or aversive stimuli that may occur during early develop-
ment or adult life. The functioning of the hypothalamic-pituitary-thyroid
axis, on the other hand, is inhibited during depression. Furthermore, a close
interaction between the HPA axis and the hypothalamic-pituitary-gonadal
axis exists. Organizing eects during fetal life, and activating eects of sex
hormones on the HPA axis, have been reported. Such mechanisms may
be the basis for a higher prevalence of mood disorders in women, as com-
pared with men [14].
Studies of rats have shown that higher levels of cumulative corticosteroid
exposure and extreme chronic stress induce neuronal damage that selectively
aects hippocampal structure. The hippocampus has been shown to aect
sleep and sleep hygiene dramatically [14].
Because various stressors activate the HPA axis, and because glucocorti-
coids are the end product of HPA axis activation, these hormones have been
viewed as the physical embodiment of stress-induced pathology. It has been
suggested that prolonged overproduction of glucocorticoids, whether as a
result of ongoing stress or a genetic predisposition to HPA axis hyperactiv-
ity, brings about damage to certain brain structures (especially the hippo-
campus) essential for HPA axis restraint. Such damage, in turn, has been
hypothesized to lead to a feed-forward circuit, in which ongoing stressors
drive glucocorticoid production indenitely. This theory has been called the
glucocorticoid cascade hypothesis [15].
Despite the popularity of the glucocorticoid cascade hypothesis, increasing
data provide evidence that in addition to glucocorticoid excess, insucient
glucocorticoid signaling may play a signicant role in the development and
expression of pathology in stress-related disorders [15]. Insucient
glucocorticoid signaling is dened as any state in which the signaling capacity

of glucocorticoids is inadequate to restrain relevant stress-response systems,
either as a result of decreased hormone bioavailability (eg, hypocortisolism)
or as a result of weakened glucocorticoid responsiveness (ie, secondary to
reduce glucocorticoid receptor sensitivity). As dened, insucient glucocor-
ticoid signaling implies no specic mechanism or absolute deciency, but
focuses instead on the end point of glucocorticoid activity. A critical function
of glucocorticoids is to shape and mobilize immune responses during stress
[15]. Virtually all stressors, including infection, physical trauma, and even
psychologic insults, are associated with immune activation and release of
proinammatory cytokines such as interleukin-1 (IL-1) and interleukin-6
(IL-6). Because of their inhibitory eects on nuclear factor signaling path-
ways, glucocorticoids are the most potent anti-inammatory hormones in
the body. They serve to suppress the production and activity of proinamma-
tory cytokines during stressor exposure and to return the organism back to
homeostasis after cessation of the stressor.
The relationship of insucient glucocorticoid signaling to stress-related
disorders has been proposed by Raison [15] as eects stemming from envi-
ronmental challenges (stress), genetic predisposition, and the inuence of
interacting systems, including neurotransmitter systems and the endocrine
system. Insucient glucocorticoid signaling is manifested most commonly
as either hypocortisolism or impaired glucocorticoid responsiveness. Inade-
quate glucocorticoid activity, in turn, prevents stress-response systems,
including the immune system, the sympathetic nervous system (SNS), and
CRH from inhibitory control, which leads to unrestrained stress hyperreac-
tivity. The resulting increased release of proinammatory cytokines, cate-
cholamines, and CRH leads to health consequences relevant to behavior,
CNS function, metabolism, and immune function. Immune activation and
cytokine release can then lead to further impairment in glucocorticoid
signaling (feed-forward cascade) through direct inhibitory eects on gluco-
corticoid receptor function (Fig. 3).
Although autoimmunity remains an ongoing risk whenever the immune
system is activated, prolonged or repeated exposure to immune stimuli
might predispose an individual to reduced glucocorticoid signaling as
a means of freeing bodily defenses from inhibitory control in the face of
an ongoing infectious threat. Such a release of inammatory processes
might be adaptive under conditions in which recurrent infection is likely
and immune readiness is an attendant requirement.
Hypothalamic-pituitary-adrenal axis and sleep

One of the most common symptoms of CSS is sleep deprivation, caused
by the eect of the HPA axis on the limbic system (eg, hippocampus and
amygdala). The early phase of nocturnal sleep, dominated by extended
periods of slow-wave sleep, is the only time of a 24-hour period in which
114 AUVENSHINE
Fig. 3. Insucient glucocorticoid signaling in the pathophysiology of stress-related disorders.

(From Raison CL, Miller AH. When not enough is too much: the role of insucient glucocor-
ticoid signaling in the pathophysiology of stress-related disorders. Am J Psychiatry 2003;
160(9):1561; with permission.)
secretory activity of the HPA axis is subjected to a pronounced and persis-

tent inhibition, resulting in minimum concentrations of ACTH and cortisol.
During late sleep, which is predominated by rapid eye movement (REM)
sleep, HPA secretory activity reaches diurnal maximum. Born and col-
leagues [16] demonstrated that early sleep, and in particular slow-wave
sleep, is associated with inhibition of pituitary-adrenocortical responsive-
ness. This association was established by comparing response to administra-
tion of exogenous secretions of ACTH in men during sleep and during
nocturnal wakefulness. It is presumed that this association is caused by
hypothalamic secretion of an as-yet unknown release-inhibiting factor of
ACTH. Born also revealed that the pituitary adrenocortical responsiveness
during early sleep was disinhibited after administration of correat, which is
a selective blocker of mineralocorticoid receptors located primarily in the
limbic-hippocampal structures. Hippocampal neuronal networks are known
to integrate corticosteroid feedback by way of the mineralocorticoid recep-
tors and the classical corticoid receptors. Born proposed that dysfunction of
the identication mode of regulation during early sleep is present in Cush-

ings disease, in patients who have severe depression, and in aged patients
[16]. The proposed connection made by the study strongly suggests that hip-
pocampal dysregulation of sleep alters the production of secretory activity
that is prominent during early sleep and does not allow for replenishing
of the immune system, making it dicult to meet the stresses of the follow-
ing day.
Medical conditions with symptoms common to temporomandibular

disorders
Temporomandibular disorders
Besides being a potential cause of various headaches, disorders of the
temporomandibular joints may contribute to a wide range of other com-
plaints, including jaw, ear, and neck pain. Numerous techniques are available
to diagnose TMDs, including imaging techniques and physical examination
[1]. Pain in the temporomandibular region appears to be relatively common,
occurring in approximately 10% of the population over age 18 [17]. TMDs
can be divided into arthralgic TMDs and myalgic TMDs (Box 3). Several
medical conditions exist that share various symptoms with TMDs.
Fibromyalgia
FM is a chronic disorder characterized by persistent, widespread pain
and abnormal pain sensitivity in response to a wide array of stimuli, such
Box 3. Classification of TMDs

Arthralgic TMDs
Congenital disorder
Disc derangements
Fracture
Dislocation
Inflammation
Ankylosis
Osteoarthritis
Neoplasia
Myalgic TMDs
Myofascial pain
Myositis
Myospasm
Local myalgia (unclassified)
Myofibrotic contracture
116 AUVENSHINE
as mechanical pressure, cold, heat, and ischemia [18,19]. Individuals with

FM also demonstrate a number of other medically unexplained symp-
toms, including fatigue, sleep disturbances, impairment in attention and
other cognitive functions, stiness of muscles and joints, and subjective joint
swellings (Box 4). It has been found that patients who have FM are charac-
terized by high levels of psychologic distress. Additional psychosocial fac-
tors, such as stressful life events and chronic pain, prompt the FM patient
to seek health care, both conventional and alternative. Consequently,
some health care providers view patients who have FM as being either hy-
pervigilant about common, unpleasant sensory experiences, or as somatizers
who seek to medicalize their symptoms [20].
Chronic fatigue syndrome

CFS describes patients who have profound, disabling fatigue, lasting up
to 6 consecutive months. It is not the result of ongoing exertion and is not
alleviated by rest. Patients experiencing CFS report a signicant reduction
in activity levels, aecting their occupational, educational, social, and per-
sonal lifestyles. CFS patients complain of such symptoms as impairment
of short-term memory or concentration, sore throat, tender cervical and
axillary lymph nodes, myalgia, arthralgia without joint swelling or redness,
headache, unrefreshing sleep, and postexertional fatigue.
Box 4. Symptoms of fibromyalgia

Musculoskeletal
Pain at multiple sites
Stiffness
Hurt all over
Swollen feeling in tissues
Nonmusculoskeletal
General fatigue
Morning fatigue
Sleep difficulties
Paresthesia
Dizziness/vertigo
Tinnitus
Raynauds phenomenon
Anxiety
Mental stress
Depression/cognitive dysfunction
Irritable bowel syndrome

IBS is characterized by chronic or recurring abdominal pain associated
with altered bowel habits that cannot be explained by biochemical or struc-
tural abnormalities. This condition appears to have a female predominance
of 2.4:1 [21]. The most prevalent symptoms reported by IBS patients are
nausea, bloating, constipation, and extraintestinal symptoms. Several stud-
ies have indicated that the menstrual cycle inuences gastrointestinal symp-
toms, which are reportedly increased immediately before and during menses.
Multiple chemical sensitivity syndrome

MCS describes a disorder characterized by a vast array of somatic, cog-
nitive, and aective symptoms, the cause of which is attributed to exposure
to low levels of various chemicals. Typically, the physical examination and
laboratory ndings of patients who have MCS do not exhibit any abnormal-
ities. MCS, as dened by Cullens [22], is an acquired disorder characterized
by recurrent symptoms, referable to multiple organ systems, and occurring
in response to demonstrable exposure to many chemically unrelated com-
pounds at doses far below those established to cause harmful eects in
the general population. MCS is a controversial disorder, with debate over
whether it is a nonpsychiatric organ disorder or a psychiatric disorder
(such as somatoform disorder), or possibly a combination of both. At pres-
ent, the exact cause of MCS is unknown; however, the proposed etiologic
mechanisms include immunologic dysregulation, limbic kindling as de-
scribed by Bell and colleagues [23], and psychologic dysfunction. Included
in the MCS debate are dental amalgam restorations. The controversy over
the deleterious health eects of mercury llings has been ongoing since
1970. The potential dangers of using silver-mercury amalgam llings in den-
tal restorations have been reported primarily by the lay media. It has been
purported to produce symptoms similar to FM, chronic fatigue, headaches,
cognitive dysfunction, and muscle and joint aches [24]. Although the fears
have been heightened in recent years, no convincing evidence currently exists
that suggests that removing amalgam restorations from patients will resolve
their chemical sensitivities.
Other associated syndromes

Hyperprolactinemia
Hyperprolactinemia is a condition of elevated levels of the serum prolac-
tin, which is produced in the lactotroph cells of the anterior pituitary gland.
Secretion is pulsatile [25]. The primary function of prolactin is to stimulate
breast epithelial cell proliferation during pregnancy, and to induce lactation.
Estrogen stimulates the proliferation of pituitary lactotroph cells, resulting
in an increased quantity of these cells in premenopausal women (especially
118 AUVENSHINE
during pregnancy). Although lactation is inhibited by high levels of estrogen

and progesterone during pregnancy, the rapid decline of estrogen and pro-
gesterone in the postpartum period allows lactation to occur [25]. Prolactin
also serves to regulate estrogen and progesterone balance.
Secretion of prolactin is under tonic inhibitory control by dopamine.
Prolactin production can be stimulated by the hypothalamic peptides,
thyrotropin-releasing hormone, and vasoactive intestinal peptide. Thus,
hyperprolactinemia can result from primary hypothyroidism (a high thyro-
tropin-releasing hormone state) [26].
Hyperprolactinemia is common in men and women. Generally, however,
the clinical presentation is more obvious and presents earlier in women, who
typically present with oligomenorrhea, amenorrhea, galactorrhea, or infer-
tility. One cause of hyperprolactinemia is a pituitary tumor. If a tumor is
present, approximately 90% of the time it is a microadenoma. A complete
drug history should be obtained from patients suspected of having hyper-
prolactinemia because many common medications can cause the disorder
[27]. Dopamine receptor antagonist drugs, such as phenothiazine; dopa-
mine-depleting agents such as reserpine; and other drugs, such as tricyclic
antidepressants, monoamine antihypertensives, and verapamil, can elevate
levels of prolactin when used over an extended period of time [28].
Laboratory tests using hormone assays can help identify hyperprolactine-
mia. Additionally, thyroid-stimulating hormone (TSH) evaluation is impor-
tant in detecting hypothyroid conditions in suspected individuals because
hypothyroidism can cause prolactin levels to escalate.
If the hyperprolactinemia is caused by a nonadenoid tumor condition,
the dopamine-agonist bromocriptine mesylate (Parlodel) is the initial drug
of choice. It lowers the prolactin level in 70% to 100% of patients [27].
Mitral valve prolapse dysautonomia

Mitral valve prolapse (MVP) is a common cardiac disorder that may
aect 5% to 20% of the general population. It is disproportionately more
prevalent among women than men. Symptoms of MVP usually do not pres-
ent before early teenage years, although adults of any age may be aected.
MVP tends to be hereditary [29].
The autonomic nervous system controls the involuntary systems of the
body, such as heartbeat, blood pressure, body temperature, intestinal func-
tions, sweating, and so forth. The system is composed of two parts: the SNS
(the accelerator) and the parasympathetic nervous system (the brakes).
When these two systems are out of balance, it is described as dysautonomia.
Dysautonomia has several categories. When the dysautonomia involves
patients who have MVP, the condition is referred to as MVP dysautonomia
or MVP syndrome. Symptoms of MVP dysautonomia include anxiety or
panic attacks, depression or mood swings, chest discomfort or pain, palpi-
tations or feelings of skipped heartbeats, vertigo, syncope or presyncope,
pallor or redness of extremities, weakness, fatigue, headaches, migraines,

and numbness or tingling in the extremities [30].
Mechanisms underlying the condition have been shown to include in-
creased adrenergic activity, disturbances in catecholamine regulation, hyper-
responsiveness to adrenergic stimulation, anomalous beta-adrenergic
receptors, dysfunction of the parasympathetic nervous system, decreased
intravascular volume, diminished left ventricular diastolic volume, and
abnormal secretion of atrial natriuretic factors. The adrenal glands and the
autonomic nervous system coexist and interact, creating a complex neuroen-
docrine-cardiovascular process, which may account for many of the symp-
toms unexplained on the basis of the valvular abnormality alone [31].
Hypothyroidism
Hypothyroidism refers to a metabolic state resulting from a deciency in
thyroid hormone function. It may arise from primary thyroid disease, hypo-
thalamic-pituitary disease, or generalized tissue resistance to thyroid hor-
mone. Early recognition of hypothyroidism remains a challenge, especially
when the decline in thyroid function is gradual [32]. Symptoms may be nonspe-
cic in early stages and do not occur necessarily in any sequence. These symp-
toms may include myalgia, arthralgia, muscle cramps, dry skin, headaches,
and dysmenorrhea. The diagnosis of primary hypothyroidism is conrmed
by a reduced free-T4 level and an elevated TSH level. Subclinical hypothyroid-
ism is diagnosed by the demonstration of elevated TSH levels in the setting of
normal, free-T4 levels [33]. The diagnosis of secondary hypothyroidism,
resulting from hypothalamic-pituitary dysfunction, can prove more dicult,
because TSH levels may be reduced, normal, or even slightly elevated in this
condition. Thyroid hormones have two major physiologic eects: they in-
crease protein synthesis in virtually every body tissue, and they increase oxy-
gen consumption by increasing the activity of sodium and potassium ATPase
(the sodium pump), primarily in tissues responsible for basal oxygen con-
sumption, such as the liver, kidney, heart, and skeletal muscle. Thyroid hor-
mone regulates both the hypothalamus and the pituitary.
Menstrual migraine
Menstrual migraine typically develops in females during their teenage
years around the onset of menstruation, and is most frequent around 40
years of age. It is unique in that it tends to be more severe, last longer,
and be less responsive to the medications normally prescribed for migraines
experienced during other times of the month [34]. Unlike typical migraine,
menstrual migraine commonly occurs without aura. According to the Inter-
national Classication of Headache Disorders published by the Interna-
tional Headache Society in 2004, menstrual migraine is categorized into
two divisions: menstrually related migraine and pure menstrual migraine
[35]. Menstrually related migraine diers from pure menstrual migraine in
120 AUVENSHINE
that the headaches do not occur exclusively around the time of menstrua-
tion, but are present at other times of the month as well. Only a small num-
ber of women experience pure menstrual migraine.
The pathogenesis of menstrual migraine is not well understood. Multiple
mechanisms have been proposed that suggest factors such as hormone uc-
tuation, central serotonin function, abnormal endogenous opioid variation,
or decreased melatonin secretion. One of the most widely cited theories
centers around the linkage of hormonal interactions triggered by steep drops
in estrogen levels just before the onset of bleeding. It has been proposed that
this decrease in estrogen may increase blood vessel susceptibility to other
factors such as prostaglandins, and this, in turn, can lead to chemical and
inammatory changes in the brain, triggering a headache [34].
The relationship between menstrual migraine and CSS can be seen in the
example of a woman who is stressed to the extent of immune system depri-
vation and sleep deprivation. In this situation, any additional insult to her
body may result in an expression of extreme headache. The fact that vascu-
lar-type headaches can occur before and around the time of menses strongly
suggests a link between menstrual migraines and CSS. Therefore, it is
important that the clinician be aware of the associated features of menstrual
migraine in the chronic pain suerer.
The use of antidepressants

Depressed patients who have HPA malfunction respond to antidepres-
sants with changes in both mood and hormones. Two major classes of an-
tidepressant drugs exist: monoamine oxidase inhibitors and monoamine
reuptake inhibitors [36]. Monoamine reuptake inhibitors are the most com-
monly prescribed group of drugs for the treatment of depression. Normali-
zation of a hyperactive HPA system occurs during successful antidepressant
pharmacotherapy. One possible mechanism for the success of antidepres-
sants could be an increase in cellular corticosteroid receptor concentration,
rendering the HPA system more susceptible to feedback inhibition by corti-
sol [13]. The inhibitory action of cortisone is exerted by way of receptor sites
localized in neurons of the hypothalamus, hippocampus, septum, amygdala,
and reticular formation [36]. The inhibitory action of cortisone on the hip-
pocampus is the reason that individuals taking tricyclic antidepressants may
enjoy a more restful sleep. By allowing an individual to obtain a more restful
sleep, HPA secretory activity can return to its diurnal maximum level.
Therefore, the use of certain antidepressants can, in fact, enhance sleep as
well as mood, facilitating restoration and normalization of the HPA system.
A new hypothesis put forth by Barden [36] suggests that a primary action
of antidepressants could be the stimulation of corticosteroid receptor gene
expression, with a resultant decrease in HPA system activity, including re-
duced expression of CRH. Reduced expression of CRH has been implicated
in the pathogenesis of depression. Thus, antidepressants may not only
increase the capacity of neurons involved in regulation of the HPA system,

but may also have a common mechanism of action at the level of corticoste-
roid receptor genes.
Clinical management
Medical management of functional somatic syndromes can be broken
into six steps, as reported by Barsky [37]:
1. Ruling out the presence of diagnosable medical disease
2. Searching for psychiatric disorders
3. Building a collaborative alliance with the patients
4. Making restoration of function the goal of treatment
5. Providing realistic reassurance
6. Prescribing cognitive behavior therapy for patients who have not
responded to the rst ve steps
Clinicians must uphold their medical mandate with an appropriate search
for previously unrecognized medical disorders. However, caution is advised
against ordering tests strictly to reassure the patient. If, in fact, the patient is
living a sick role, the clinician must understand the risks of solidifying the
patients conviction that his/her distress has a biomedical cause. It is also
helpful to have evidence-based guidelines for appropriate evaluation.
The goal of treatment becomes the identication and alleviation of fac-
tors that amplify and perpetuate the patients symptoms and cause func-
tional impairment. The focus of management should be on coping rather
than on curing, and on improving functional status rather than simply erad-
icating symptoms. Realistic incremental goals should be set and specied in
terms of observable behavior. Patients should be encouraged to resume their
activities as much as possible and to remain at work if they are at all able to
do so [37].
Cognitive-behavioral therapies can be eective in treating persistent dis-
tress and disability resulting from functional somatic syndromes, if previous
strategies have proved insucient. Such therapies have been developed for
somatoform disorders and some medically unexplained symptoms, such as
IBS, FM, CFS, headaches, atypical chest pain, and atypical facial pain.
These cognitive-behavioral interventions help patients cope with symptoms
by teaching them how to reexamine their health beliefs and expectations,
and how to explore the eects of the sick role, stress, and distress on their
symptoms. Cognitive interventions also enable patients to nd alternative
explanations for their symptoms and to restructure faulty disease beliefs.
Clinical evaluation
The evaluation of a patient who has chronic pain is a complex process.
Arriving at a diagnosis is typically insucient to guide treatment because
122 AUVENSHINE
any given pain diagnosis has a large heterogeneity with respect to symptom
causes. Because of this heterogeneity, the most eective treatments can
sometimes be elusive. The dierential diagnosis of the chronic pain suerer
involves identifying which factors are present in a given individual, to
narrow the eld of potential somatic disorders.
A complete history and examination remains the most important diag-
nostic tool. The key to collecting a thorough history is the quality of the pa-
tient interview. It is vital that the practitioner listen carefully to the patient
and understand what the patient is (or is not) saying. Knowing the right
questions to ask is crucial to extracting the correct information. The inter-
viewer should begin with the patients chief complaint. It is essential to
determine the location, onset, quality, frequency, duration, and intensity
of the pain; any associated symptoms; precipitating, aggravating, and reliev-
ing factors; and prior treatment. Once the clinician has obtained this infor-
mation, a more accurate diagnosis can be made. Lasagna [38] stated, The
investigator who would study pain is at the mercy of the patient, upon
whose ability and willingness to communicate he is dependent.
Clinical studies
38-year-old woman
A 38-year-old woman appeared in the authors oce with the chief com-
plaint of chronic, daily headaches with pain localized in the right and left
temple area. This pain radiated down the face and into the ears and tempo-
romandibular joints. She stated that she began having headaches several
months prior, and waking up in the morning with a pool of blood in
her mouth. She went to her ear, nose, and throat specialist (ENT), who per-
formed a CT scan of the sinuses. However, the scan appeared normal. She
then visited another ENT for a second opinion. This physician told her that
he saw no abnormalities in her sinus and to see her dentist for possible
TMD. Her dentist referred the patient to the authors oce.
The patient reported that she had a history of migraine headaches and
recently had changed neurologists in an eort to wean o pain medication,
because of fear of rebound headaches. She stated that she had diculty fall-
ing asleep and was a poor sleeper once she did. She reported that she fre-
quently awoke in the middle of the night with head and neck pain, and
an awareness that her teeth were clenched together. She also complained
of neck stiness and soreness, and occasional popping of her left temporo-
mandibular joint. She stated that she was taking medication for depression,
acid reux, and IBS, and was also taking a sleep aid. In total, she reported
taking nine medications at that time.
Because the patient was treated previously with an intraoral orthotic
appliance for nighttime use and desired to reinstitute that treatment,
a new appliance was fabricated. She was assured that hers was a complex
case involving many factors, largely stress-induced. It was the authors rec-
ommendation that she remain under the care of her physician and that they
discuss the possibility of behavioral and cognitive counseling to learn coping
mechanisms regarding her stress response.
The patient was placed on a 4-week recall and was given instructions to
wear the maxillary orthotic appliance on a full-time basis, removing it
only to eat and brush her teeth. In addition, palliative instructions were
given regarding passive stretching exercises, along with ice, moist heat,
and muscle massage with stretching before bedtime. The patient complied
with the authors request for behavioral counseling and pursuing other
forms of relaxation. Before treatment, she felt as though life was over-
whelming and that she had no control over the situation in which she
lived. Part of her coping mechanism for the perceived lack of control
was to exert control over any portion of her environment where she could.
She stated that she would constantly become involved in many projects
without completing previous ones. With treatment, she learned to limit
the number of projects in which she became involved, and to complete
a project before beginning a new one. As she complied with these types
of suggestions and care, she was able to eliminate all but two of her
medications.
62-year-old man
A 62-year-old male patient presented between recall appointments with
the chief complaint of severe, debilitating headaches. He reported that the
headaches occurred on waking in the morning and lasted until bedtime.
The headaches reached maximum intensity at midday and decreased slowly
in intensity until he went to bed. An always underlying level of chronic pain
varied from level 4 to as high as 8.5 on a visual analog scale. The patient
stated that these headaches began approximately 3 weeks before his visit
to the authors oce. He had sought help from his primary care physician,
who placed him on an analgesic and a muscle relaxant.
The patient was already under long-term care for nocturnal bruxism. He
was using a maxillary intraoral orthotic appliance constructed of hard
acrylic. He had been instructed to wear the appliance for at least 8 hours
at night while sleeping, and was on a 6-month recall. Because he felt that
his headaches could be related to his bruxism, he came to the authors oce
for an evaluation before further testing by his physician.
On examination, heavy wear facets were observed on the appliance. Ad-
justments were made to the appliance, and a recommendation was given to
increase the wearing time from 8 hours to 12 hours in each 24-hour period.
He was instructed to place the appliance in his mouth shortly after dinner
and wear it until he awakened the next day. Other palliative care was recom-
mended, such as the use of moist heat, soft diet, and so forth. The patient
was instructed to return to the authors oce in 1 week. He was also
124 AUVENSHINE
encouraged to pursue the tests that his physician had ordered to rule out any
catastrophic ndings.
The patient returned 1 week later, stating that he had undergone an MRI.
The report indicated no signicant soft tissue ndings. However, it strongly
suggested compression at C1 and C2, and a slight bulging of the disc be-
tween C3 and C4. He had also undergone a blood test, which revealed no
abnormalities. On further evaluation, it was discovered that the patient
had retired twice, but was unhappy not working. He had returned to
work at a job that required a great deal of travel to foreign countries. He
had thought this travel would be enjoyable; however, the current project
to which he had been assigned had proven extremely stressful. It had been
assigned just 2 weeks before the onset of his severe headaches. He was as-
sured that the next trip he went on would cost him his job if it failed.
He reported that because of this stress, he had not had a complete nights
sleep in weeks.
Based on this information, it was the authors feeling that the patients
stressful occupational situation, his inability to sleep, and his bruxing habit
were all leading to cervicogenic headaches. After consulting the patients
physician, the author recommended that the patient be placed on an antide-
pressant at night, receive physical therapy for the neck and shoulders, and
continue the other palliative care recommended previously. Within 3 weeks
of this treatment regime, the patient began to experience relief from his
headaches and to return to normalization.
10-year-old girl
A 10-year-old girl presented with the chief complaints of continual head
pressure and daily headaches. She stated that she would awaken with a head-
ache, which would last throughout the day and still be present when she
went to bed. She reported that the headaches began approximately a year
before her visit to the authors oce; however, the headaches had intensied
over the previous 5 weeks to the point where they now included pain in the
neck and shoulders. She stated that simply touching the head caused pain
throughout her entire body. She was taking adult-strength acetaminophen
and Motrin without relief. She preferred to be in a dark room because light
intensied her pain. She stated that she had not slept well since the head-
aches began. She explained that lying down was painful, as was sitting up.
She complained of dizziness and of a feeling of weakness because of pain
in her legs.
A clinical examination revealed tender points primarily in the anterior
temporalis and suboccipital region of the head. The patient was orthodon-
tically skeletal class I with a deep bite and poor anterior tooth contact. She
was in mixed dentition.
It was recommended that the patient enter treatment with an intraoral
orthotic appliance to add anterior guidance to the functional parameters
of the stomatognathic system. It was also recommended that she wear the
appliance on a full-time basis for the rst 4 to 6 months, removing it only
to eat and brush her teeth. In addition to wearing the appliance, the patient
was instructed to perform stretching exercises for her jaw and cervical mus-
culature. It was strongly suggested that she visit her primary care physician
for a complete evaluation, including imaging.
The results of the diagnostic tests performed by her physician were all
negative, including no signicant ndings from an MRI of the head and
neck. The physician placed her on a low dose of amitriptyline and an
anti-inammatory on a time-contingent basis. Her physician proposed
migraine medication to the patients parents for her headaches.
During follow-up visits, the patient reported better sleep and that her
headaches had begun to improve. At subsequent appointments, it was
learned that the headaches began shortly after she and her family moved
into a new home in a new neighborhood. The move required her to change
schools (which meant new friends and teachers). She was exposed to a di-
cult teacher who she felt did not understand her. As a result of the demands
placed on her at this new school, she became depressed and began to expe-
rience vivid dreams, which further impacted her performance in school. Al-
though she had been a straight-A student in her previous school, she was
now struggling to deal with her complicated situation. Once her parents
learned of the true scope of the problem and took steps to remedy it, the
patient began to make dramatic improvements in her pain complaints.
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Dent Clin N Am 51 (2007) 129144
Temporomandibular Disorders
and Headache
Steven B. Gra-Radford, DDS
The Pain Center, Cedars-Sinai Medical Center, 444 South San Vicente,
#1101 Los Angeles, CA 90048, USA
Headache is a common symptom, but when severe, it may be extremely

disabling. Although the most common headache is tension-type headache,
it rarely is severe enough to require medical attention. Migraine is the head-
ache that is seen most commonly by physicians. The disorder aects 28 mil-
lion Americans, yet only 50% are diagnosed as migraine. Many patients are
believed to have tension-type headache and sinus headache. It is assumed
that patients who present to dentists with headache often are diagnosed
with a temporomandibular disorder (TMD), although many may have
migraine. TMD as a collective term may include several clinical entities,
including myogenous and arthrogenous components. Pain in the
temporomandibular joint (TMJ) may occur in 10% of the population [1],
and TMDs have been reported in 46.1% of the United States population
[2]. Because headache and TMD are so common they may be integrated
or separate entities. Nevertheless, the TMJ and associated orofacial struc-
tures should be considered as triggering or perpetuating factors for
migraine. Ciancaglini and Radaelli [3] reported that headache occurs
signicantly more frequently in patients who have TMD symptoms
(27.4% versus 15.2%). It is important that the clinician considers peripheral
and central processes that may contribute to headache. Often, ignoring the
TMJ, muscles, or other orofacial structures as a peripheral trigger results in
a poor clinical outcome in managing headache; at the same time, not mak-
ing the correct diagnosis may lead to unnecessary therapy and poor out-
come. The trigeminal nerve is the nal conduit of face, neck, and head
pain [4]. As a result of the central connections, it is possible for referral to
occur between divisions [5]. The management of pain in the rst division
may be inuenced by therapy that is aimed at structures that are innervated
130 GRAFF-RADFORD
by the second or third trigeminal division. Therefore, it is important that

cause and eect connections between TMD and headache are judged care-
fully. This article discusses the relationship between the TMJ, muscles, or
other orofacial structures and headache.
The teeth and headache

The pathology that is associated with dental disease is not a common
cause of headache. Dental disease may be summarized as pulpal or peri-
odontal. Pulpal pain may be characterized as an irreversible pulpitis, where
pulpal tissue death is inevitable and results in root canal therapy. Reversible
pulpitis may be resolved by eliminating the inciting pathology (eg, caries).
Periodontal disorders involve the supporting teeth structures, the bone, peri-
odontal ligament, and cementum. Periodontal disease triggers tissue inam-
mation, which often produces pain and swelling in the aected site. When
acute pain occurs in the dental structures, patients often describe referred
pain and tenderness to adjacent structures, including headache. The fre-
quency and epidemiology of headache and tooth pain is unknown. Head-
ache usually is a secondary phenomenon and it does not pose a signicant
diagnostic dilemma. Pericoronitis may be the most frequent periodontal in-
ammation that causes headache. Pericoronitis, as its name implies, results
from infection or traumatic irritation around a partially erupted tooth, usu-
ally a third molar.
These dental problems are managed best with conventional dental ther-
apies, and rarely produce any long-term or signicant disability. Chronic
dental pains are dierent, however. Atypical odontalgia (AO) has been
linked with headache and described as possible secondary to a migrainous
etiology [6,7]. Unfortunately, atypical facial pain has become a wastebasket
term for all pains in the face that are not diagnosed readily. Harris [8] rst
described AO as slightly more specic because it is localized to the tooth
site. Gra-Radford and Solberg [9,10] dened AO as pain in a tooth or
tooth site where no organic cause is obvious. They emphasized that before
making a diagnosis, positive inclusionary criteria are required, rather than
arriving at the diagnosis by exclusion. Gra-Radford and Solberg [11,12]
suggested a deaerentation mechanism; peripheral, central, or sympatheti-
cally maintained pain usually is present when patients are labeled atypi-
cal. The relationship of psychopathology and AO also has been
explored by Gra-Radford and Solberg [13], and no positive relationship
was found between psychologic diagnosis and the pain. It is most likely
that these pains are neuropathic, and follow some neural injury or sensiti-
zation; they can be divided into pains that are mediated by the sensory sys-
tem or the sympathetic system [12]. Therefore, criteria are proposed for
dening neuropathic facial pain. The correct term should be trigeminal
deaerentation. The criteria for trigeminal deaerentation include
TEMPOROMANDIBULAR DISORDERS AND HEADACHE 131
continuous pain that is punctuated with sharp electric pains and requires
four of the following:
Known trauma
Presence of neurosensory decit (numbness)
Allodynia
Hyperalgesia
Temperature change
Block eect (somatic or sympathetic)
Patients who have persistent facial pain may report an increase in their
headache frequency. This may result from nociceptive stimuli that trigger
migraine or a change in central pain inhibition that lowers the migraine
threshold. Nevertheless, headache management may be achieved best by ad-
dressing the peripheral trigger and the migraine independently. Medications
that are used commonly to manage the neuropathic facial pain also may de-
crease the migraine frequency; however, patients also should be provided
with an acute or abortive migraine-directed medications (eg, triptans).
Migraine and facial pain

Lovshin [14] was the rst to describe migraine as a facial pain problem
that could occur without pain in the rst division of the trigeminal nerve.
The pain in facial migraine is described as dull pain, with superimposed
throbbing that occurs once to several times per week. Each attack may
last minutes to hours. Raskin and Prusiner [15] described ipsilatertal carotid
tenderness in facial migraine, a nding that also is seen when migraine oc-
curs in the head. This condition also has been referred to as carotidynia.
Treatment of facial migraine is no dierent from that for migraine that pres-
ents in the head. All treatments should include an understanding that the
disorder is genetic, and that the goals should be to reduce pain frequency
and intensity, restore function, and provide a sense of self-control. Therapy
may involve nonpharmacologic and pharmacologic approaches. In general,
addressing triggering factors through diet, exercise, and sleep is rst-line
care. The acute attack is treated by administration of the most eective ther-
apy early. Analgesics, anti-inammatories, ergots, and triptans are used
most commonly. If the headache is frequent, preventative medications
may be considered. The groups of medications that may be considered are
b-blockers, calcium channel blockers, antidepressants, antiepileptic (mem-
brane-stabilizing) drugs, and antiserotonin drugs [16].
Temporomandibular disorders and headache

Scientic investigation has described the pathways and mechanisms for
pain referral from the head to the TMJ and vice versa [17]. Headache
may result from temporomandibular structures or pain may be referred to
132 GRAFF-RADFORD
the TMJ, secondary to a primary headache diagnoses. Functional disorders

and pain in the anatomic region of the TMJ and associated musculature are
referred to as TMDs. This overlap primarily is related to the anatomy and
neural innervations. It is essential not to confuse the issue and suggest
a cause and eect relationship based on treatment responses. Because the
trigeminal nerve is the nal pathway for head pain and TMDs, it makes
the relationship between TMDs and headache confusing. It is suggested
that the two are separate, but may be aggravating or perpetuating factors
for each other. Patients who have primary headache can see their pain wors-
ened or triggered when there is a coexisting TMD.
Epidemiology
TMD epidemiology has not dierentiated headache from facial pain spe-
cically. In nonpatient population studies, 75% of subjects have at least one
joint dysfunction sign (clicking, limited range of motion) and about 33%
have at least one symptom (pain, pain on palpation). Out of the 75% of sub-
jects who have a sign or symptom, fewer than 5% require treatment; even
fewer have headache as the primary pain location. Headache is referred to
often in TMD studies, but few dene its etiology. This makes it dicult
to determine the relationship of TMD etiology and therapy in specic head-
ache types.
Etiology
Inammation within the joint accounts for TMD pain, and the dysfunc-
tion is due to a diskcondyle incoordination. Muscle pain disorders may in-
clude spasm, myositis, muscle splinting, and myofascial pain. Myofascial
pain is the most frequent muscle disorder that is included in TMD classi-
cation. Although each may be a trigger for headache and they can occur
together, they are discussed separately.
Inammation
Primary inammatory conditions of the TMJ include capsulitis, synovi-
tis, and the polyarthritides. Polyarthritides are uncommon and are associ-
ated primarily with rheumatologic disease. Inammatory conditions, such
as synovitis or capsulitis, frequently occur secondary to trauma, irritation,
or infection, and they often accompany other TMDs [18].
Several proinammatory cytokines have been detected in painful TMDs,
which suggests that they may play a role in pain [19]. Capsulitis, an inam-
mation of the capsule that is related to sprain of capsular ligaments, is clin-
ically dicult, if not impossible, to dierentiate from synovitis. The pain
that is related to capsulitis increases during all translatory movements and
joint distraction, but not usually during clenching, however [20]. Both
conditions may be accompanied by a uctuating swelling (due to eusion)

that decreases the ability to occlude on the ipsilateral posterior teeth. Pain
that is associated with inammation is localized to the TMJ capsule and
the intracapsular tissues. Typically, the pain is dull achy, but it may be
throbbing. It is described frequently as sharp with jaw movements. The
pain is continuous, but worsens with jaw function.
Disk derangement disorders

Articular disk displacement is the most common TMJ arthropathy; it is
characterized by several stages of clinical dysfunction that involve the
diskcondyle relation. The usual direction for displacement is anterior or
anteromedial [21,22], although other directions have been described. Pain
or mandibular movement symptoms are not specic for disk derangement
disorders [23], and disk position may not be related to any presenting symp-
tom [24,25].
The causes of disk displacement are not agreed upon; however, it is pos-
tulated that in most cases, stretched or torn ligaments that bind the disk to
the condyle permit the disk to become displaced [26] An increased horizon-
tal angle of the mandibular condyle has been associated with more advanced
TMJ internal derangement [27,28] Lubrication impairment also has been
suggested as a possible etiologic factor of disk displacement [29]. Disk
displacement is subdivided into disk displacement with reduction or disk
displacement without reduction.
Disk displacement with reduction

Disk displacement with reduction is described when a temporarily mis-
aligned disk reduces or improves its structural relation with the condyle
when mandibular translation occurs during opening. This produces a joint
noise (sound) that is described as clicking or popping. Disk displacement
with reduction usually is characterized by reciprocal clicking, a reciprocal
noise that is heard during the opening movement and again before the teeth
occlude during the closing movement. Because disk displacement with re-
duction is so common, it may represent a physiologic accommodation with-
out clinical signicance [30,31]. Clicking in reducing disk displacement is not
pathologic, because more than one third of an asymptomatic sample can
have moderate to severe derangement, and as many as one quarter of click-
ing joints show normal or only slightly displaced disk positions. Disk dis-
placement may or may not be a painful condition. If the condition is
painful, inammation of the retrodiskal tissue, the synovial tissues, the cap-
sule or the ligaments, or pressure and traction on the disk attachments are
more likely the causes of the pain [32]. TMJ disk displacement with reduc-
tion may persist for several years up to decades without progression or com-
plication [33]. de Leeuw and colleagues [33] reported that if clicking in
patients who have disk displacement with reduction does not respond to
134 GRAFF-RADFORD
treatment and is still present after 2 to 4 years, it is likely to persist for

several decades. Disk displacement with reduction may progress to disk
displacement without reduction. This condition is characterized by the
sudden cessation of clicking and the sudden onset of restricted mouth
opening, and frequently is accompanied by pain.
Disk displacement without reduction

Disk displacement without reduction is a permanently displaced disk that
does not improve its relation with the condyle on translation. When acute, it
is characterized by sudden and marked limited mouth opening because of
a jamming or xation of the disk secondary to disk adhesion, deformation,
or dystrophy. Often, pain is present and is related especially to the patients
attempt to open the mouth. The acute stage is manifested clinically as
a straight-line deection to the aected side on opening, a marked limited
laterotrusion to the contralateral side, and a lack of joint noise in the af-
fected joint. As the condition becomes chronic, the pain is reduced markedly
from the acute stage to the point of becoming nonpainful in many cases; the
opening range may approach normal dimensions over time [34]. If chronic,
there usually is a history of joint noise or limitation of mandibular opening
[35]; the condition may progress to reveal radiographically visible osteoar-
thritic changes. Generally, disk displacement is treated with reassurance
and education, rest, instructions to avoid loading, control of contributing
factors, and mobility exercises within the pain-free range. In the presence
of pain, mild analgesics or anti-inammatory medications are the drugs of
choice. Additional management may consist of splint therapy, physical ther-
apy, arthrocentesis, or arthroscopy to restore range of motion. In an acute
disk displacement without reduction, one may try to reduce the disk manu-
ally and temporarily maintain the diskcondyle relationship with an ante-
rior repositioning splint. This splint holds the lower jaw forward of its
resting position, thereby translating it with the objective of keeping the
disk in a favorable position. Outcome is poor. When the disk cannot be re-
duced, a stabilization appliance can be part of the treatment for painful disk
displacement with or without reduction. The high degree of spontaneous re-
duction of symptoms has to be taken into account before recommending
any kind of treatment. Surgical treatments, such as arthroscopy and open
joint surgeries, may be considered, but only after reasonable nonsurgical ef-
forts have failed and the patients quality of life is aected signicantly [36].
Myofascial pain
Myofascial pain is characterized as a regional muscle pain, described as
dull or achy and associated with the presence of trigger points in muscles,
tendons, or fascia [3739]. Myofascial pain is a common cause of persistent
regional pain (eg, neck pain, shoulder pain, headaches, orofacial pain) [40].
The major characteristics of myofascial pain include trigger points in mus-
cles and local and referred pain. A trigger point is identied as a localized
area of tenderness in a nodule or a palpable taut band of muscle, tendon, or

ligament. The trigger points may be active or latent. Active trigger points are
hypersensitive and display continuous pain in the zone of reference that can
be altered with specic palpation. Latent trigger points display other char-
acteristics of trigger points, such as increased muscle tension or muscle
shortening, but do not produce spontaneous pain. Usually, the pain is
dull and deep in quality, diuse in nature, and present in subcutaneous tis-
sues, including muscle and joints.
Myofascial therapy can be directed peripherally or centrally. The empha-
sis must be on management and controlling perpetuating factors, while
enhancing central inhibition. Active relaxation exercises, spray and stretch,
acupressure, ultrasound, deep massage, moist heat, electrical stimulation,
transcutaneous electrical nerve stimulation, biofeedback, relaxation tech-
niques, cognitive-behavioral techniques, occlusal stabilization appliances,
myofascial release, pharmacotherapy (eg, nonsteroidal anti-inammatory
drugs, muscle relaxants, tricyclic antidepressants), needling, and inltration
of taut bands with local anesthetic alone or combined with botulinum toxin
have been used [4144].
Increased tenderness in pericranial muscles is the most prominent clinical
nding in patients who have tension-type headache and migraine. The rela-
tionship between local tenderness (as seen in trigger points) and general
tenderness (as seen in allodynia associated with migraine) must be dieren-
tiated. The rst indication that there may be a correlation with the muscle
tenderness and pain was shown in experiments by Kellgren [45]. He injected
an algesic substance (hypertonic saline) into the muscle, and asked the sub-
jects to dene the area in which they perceived pain. The subjects who re-
ceived the hypertonic saline injections mapped out patterns of referral
similar to those seen in tension-type headache. Further, he injected local
anesthetic into similar areas after the pain was initiated and could abolish
the pain. These tender points became known as myofascial trigger points.
The question that may be asked is Under what circumstances could referral
take place in the patterns described?.
Mense [4648] described a hypothesis for muscle pain referral to other
deep somatic tissues remote from the original muscle stimulation site. He crit-
icized the convergence-projection pain referral theory because there is little
convergence evident at the dorsal horn from deep tissues. Menses hypothesis
adds two new components to the convergence-projection theory. First, the
convergent connections from deep tissues to dorsal horn neurons are opened
only after nociceptive inputs from muscle are activated. The connections that
are opened after muscle stimuli are called silent connections. Second, the re-
ferral to muscle, beyond the initially activated site, is due to central sensitiza-
tion and spread to adjacent spinal segments. The initiating stimulus requires
a peripheral inammatory process (neurogenic inammation). In the animal
model that was described by Mense, the noxious stimulus was bradykinin in-
jected into the muscle. In the work by Kellgren, a hypertonic saline solution
136 GRAFF-RADFORD
was used to trigger the referred pain. This seems to mimic what is seen in the
animal model. It is unclear what triggers the muscle referral in the clinical set-
ting where there usually is no obvious inammation-producing incident.
Menses theory was used by Simons [49] to discuss a neurophysiologic basis
for trigger point pain. Simons hypothesized that when the tender area in
the muscle is palpated, there is a neurotransmitter release in the dorsal horn
(trigeminal nucleus) that results in previously silent nociceptive inputs becom-
ing active. This, in turn, causes distant neurons to produce a retrograde re-
ferred pain. This model accounts for most of the clinical presentation and
therapeutic options that are seen in myofascial pain, but it does not account
for what initiates the peripheral tenderness that must be present to activate the
silent connections. Perhaps a central nervous systemactivated neurogenic in-
ammation, similar to migraine, stimulates nociceptors in muscle, rather than
around the blood vessel. Calcitonin generelated peptide, neurokinin A, and
substance P have been used to demonstrate their contribution in myofascial
pain [50]. Fields [51] described a means whereby the central nervous system
may switch on nociception. He described the presence of on cells, which,
when stimulated, may produce activation of trigeminal nucleus nociceptors.
In 1991, Olesen and Jensen [52] were the rst to suggest a relationship
between myofascial pain and tension-type headache. They proposed a
vascular-supraspinal-myogenic model for headache pain. This model hypoth-
esizes that perceived pain (headache) intensity is modulated by the central ner-
vous system. In tension-type headache, the inputs primarily are myofascial,
whereas in migraine these inputs are vascular. This model helps to explain
why the clinical presentation and treatment options often are similar for mi-
graine and tension-type headache, and why there is only temporary relief
with peripheral treatments (eg trigger point injections). The resultant hyperal-
gesia or trigger point sensitivity in myofascial pain may represent a peripheral
sensitization to serum levels of serotonin. Ernberg and colleagues [53] showed
a signicant correlation between serum serotonin levels and allodynia that is
associated with muscular face pain. Based on this information, it is proposed
that in patients who present with dull aching head pain and related muscle ten-
derness, the cause may be myofascial pain. In other words, myofascial pain
and tension-type headache may be associated with the same or similar mech-
anisms. Bendtsen [54] hypothesized that central neuroplastic changes may
aect the regulation of peripheral mechanisms that lead to increased pericra-
nial muscle activity or release of neurotransmitters in the muscle tissues. By
these mechanisms, the central sensitization can be maintained even after the
initial eliciting factors are gone. This may account for conversion of episodic
headache into chronic tension-type headache.
Treating headache by targeting temporomandibular disorders

Because there are believed to be several etiologic factors involved in
TMDs, it is to be expected that there are several therapeutic approaches.
Unfortunately, most of the literature concerning the treatment of TMDs

consists of uncontrolled observations; less than 5% of treatment studies
have been controlled clinical trials [55]. Even these are sometimes compro-
mised by weaknesses in their design. Thus, only general conclusions can
be drawn regarding treatment eectiveness. When the eects of dierent
treatments are compared, the results seldom reveal major advantages of
one method over another. Elimination of the cause would be the most eec-
tive treatment; however, if the cause cannot be identied, symptomatic
treatment has to be provided. The goals of treatment are to decrease pain,
decrease adverse loading, and restore normal function. Because the signs
and symptoms of TMDs can be transient and self-limiting, simple and re-
versible treatments have to be preferred over complicated and irreversible
procedures.
Nonsurgical treatment
In an uncontrolled study, 33 patients who had TMDs were treated with
occlusal splint (OS) therapy [56]. Following 4 weeks of therapy, 64% of pa-
tients reported a decrease in the number of weekly headaches; 30% showed
a complete remission of headache. Patients who had a high frequency of
headaches (R4 per week) seemed to respond more favorably to OS therapy.
In another uncontrolled study with patients who had TMDs, changes in
headache were followed 1 year after the start of TMD treatment [57]. The
treatment consisted of OSs, therapeutic exercises for masticatory muscles,
or occlusal adjustmentdmost often combinations of these measures. Se-
venty percent of the patients reported less frequent headaches than 1 year
earlier. Forty percent reported less severe head pain. The results achieved
seemed to be lasting at a 2.5-year follow-up [58]. These studies, however,
did not control for the placebo eect, and the type of headache being treated
was not stated clearly. Furthermore, one cannot know what part of the
treatment was necessary.
Vallon and coworkers [5961] assessed the eects of occlusal adjustment
on headache in patients who had TMDs. Fifty patients were assigned ran-
domly to a treatment group or a control group that received counseling
only. The treatment outcome was evaluated after 1, 3, and 6 months and
2 years by a blinded examiner. No signicant dierences were found regard-
ing changes in frequency of headache. The problem with the study was the
signicant drop-out of patients, which ranged from 20% at the 3-month fol-
low-up to 66% at 2 years.
A new form of splint therapy has been suggested to manage headache ef-
fectively. Shankland [62] suggested an intraoral Nociceptive Trigeminal In-
hibition Tension Suppression System (NTI-tss) device for the reduction of
frequency and severity of tension-type and migraine headaches, as com-
pared with the known ecacy of the noncommercially available full-
coverage OS. A multicenter open-labeled trial was conducted to determine
138 GRAFF-RADFORD
the response in patients who had migraine. The NTI-tss is a small intraoral
device that is tted over the two maxillary central incisors; it has a dome-
shaped protrusion that extends lingually. The dome is customized by the
provider to act as single-point contact at the incisal embrasure of the two
mandibular central incisors, thereby preventing posterior or canine tooth
contact. Following a 4-week pretreatment baseline observation, patients
were instructed to insert and wear their device during sleepdand as required
during perceived stressful times during the daydfor eight consecutive
weeks. A control devicedmandibular full-coverage OSdwas used.
Ninety-four patients were studied and randomized to the NTI-tss (n 43)
or full coverage OS (n 51). Although this was a migraine study, it seems
that patients had chronic tension-type headache. The statistical analysis is
confusing, because no information is given on pretreatment days of head-
ache and outcome is reported as the number of headaches reduced. As
with many other intraoral appliance studies, it is dicult to correlate out-
come with pharmacologic studies of prevention, because the patient selec-
tion, outcome criteria, and statistical analyses are confusing. This is not
to detract from the concept that managing a TMD in a patient who has mi-
graine may reduce headache frequency.
Because TMDs are believed to have a multifactorial etiology, it is as-
sumed that the best treatment results are achieved by using several treatment
methods to eliminate as many predisposing and perpetuating factors as pos-
sible. This assumption was addressed in a randomized, controlled study that
compared the eects of occlusal equilibration with other forms of TMD
therapy in patients who had signs and symptoms of TMDs, including head-
ache [63]. The TMD therapy consisted of OSs as well as muscle exercises and
minor occlusal adjustment in some cases, whereas the comparison group re-
ceived only occlusal equilibration therapy. The reductions in the symptoms
of TMD and the frequency and intensity of headache were signicantly
greater in the group that received combined therapy.
Some studies that focused on signs and symptoms that are attributable to
TMDs have been performed on patients who have a variety of diagnoses. In
a series of studies, 100 patients who had recurrent headache and were re-
ferred for neurologic examination were invited for a functional examination
of the stomatognathic system [64]. In total, 55 patients displayed pain that
was caused by a TMD. The pain was determined to be of myogenous origin
in 51 patients and of arthrogenous origin in 4 patients. The 55 patients were
divided randomly into two groups [65]. One group was treated by the neu-
rologist with conventional headache treatment regimes; the other group was
treated with stabilization splints for 6 weeks, and, in some cases, with phys-
ical therapy. Headache frequency decreased in 56% of the patients who
received treatment for TMDs (compared with 32% of the patients who re-
ceived neurologic treatment). There also were signicant dierences in the
reduction of headache intensity and in the use of symptomatic medication
to abort a headache at the time of onset. Thus, the clinical result of TMD
therapy exceeded the results of the neurologic treatment in patients in whom

headache was assumed to be related to TMD. The confounding factor is
that the group that received treatment for a TMD had a much greater expo-
sure to the treating clinician, which could account, in part, for the dierence.
A randomized, controlled trial by Forssell and colleagues [66] evaluated
the eect of occlusal adjustment versus a mock adjustment on tension-type
headache using a double-blind study design. The subjects included 56 pa-
tients who had tension headaches (20 of them also had migraine [ie, combi-
nation headache]) from a neurologic clinic. Most of them reported
subjective symptoms of TMD, and signs of TMD were registered in all pa-
tients. Patients were assigned randomly to active and placebo groups, and
after a 4- to 8-month follow-up period a neurologist evaluated the treatment
outcome. The headache frequency and intensity were reduced in 80% and
47%, respectively, of patients who had active treatment (50% and 16%, re-
spectively with placebo). Some of the patients who received placebo and had
moderate to severe TMD symptoms were treated with occlusal therapy af-
terwards [67]. A signicant reduction in headache frequency also was ob-
served in these patients. Except for the possible confounder that the same
clinician performed both treatments (active and placebo) unblinded, this
study again supports the value of TMD treatment for tension-type headache
that is associated with TMD signs and symptoms.
Contradictory results were reported by Quayle and coworkers [68] in an
uncontrolled study of patients who had headache and were treated with soft
OSs for 6 weeks. Many patients who had migraine-type headache improved,
but most patients who suered from tension headache failed to benet from
splint therapy. The small number of patients (n 9) in the group that had
tension headache may reduce the signicance of the result.
In the double-blind trial by Karppinen [69], 44 patients who sought treat-
ment for chronic headache and neck and shoulder pain received a routine
battery of physical therapy. In addition, 23 of the patients were allocated
randomly to occlusal adjustment and 21 received mock adjustment. Patients
were followed up at 6 weeks and 12 months. The short-term response to
physical therapy was good and was not associated with the type of occlusal
treatment. At 12 months, the eects of treatment began to subside in the
group that received mock adjustment, but further improvement was evident
in the group that had occlusal adjustment. A statistically signicant decrease
in the occurrence of headache was observed with the real adjustment com-
pared with the mock adjustment. In a qualitative systematic review of ran-
domized controlled trials of analysis of occlusal therapies for TMD, Forssell
and colleagues [70] concluded that there was insucient evidence to support
the use of occlusal adjustments, and suggestive evidence for splint therapy.
Because several controlled clinical trials seem to suggest that TMD treat-
ment can be eective for headache, the question arises whether some special
features could, in practice, help to single out patients whose headache is re-
lated to TMD. Reik and Hale [71] suggested that patients who had
140 GRAFF-RADFORD
continuous unilateral headache had a TMD. This was not supported by

Schokker and colleagues [72], who found that headaches that were respon-
sive to TMD treatment mainly were bilateral and showed only a tendency to
be present permanently. In that study, patients who had headaches that
were linked to TMD showed a greater dierence between passive and active
mouth opening recorded before treatment. This is considered to be a sign of
myogenous origin of TMD. Another study showed that patients who had
reported pain while chewing responded more favorably in terms of headache
reduction following TMD therapy [73]. Pain while chewing is one of the
most common subjective symptoms of TMD.
Several investigators who performed systematic reviews of the TMD lit-
erature concluded that there is evidence to support the use of stabilization
splints in patients who have more severe TMDs, but weak evidence to sup-
port their use with mild TMDs. Care should be taken to avoid repositioning
therapy of partial coverage therapy because it may result in signicant
changes to the occlusion [7476].
Surgical treatment
TMJ surgery is considered to be useful treatment for certain TMDs.
There are few studies that examined surgery and response to headache. Val-
lerand and Hall [77] reported on 50 patients who were diagnosed with inter-
nal TMJ derangements, myalgia, and headaches who had not responded to
nonsurgical management. The surgical procedures that they underwent in-
cluded disk repositioning, repair of disk perforation, disk recontouring, lysis
of adhesions, and diskectomy. In the retrospective evaluation, most patients
reported decreases in headache as well as decreases in joint pain and noise.
The surgeons suggested that the change in head pain is a secondary result of
decreasing joint pain, which allowed the patients to cope better with other
pains. In another study, Montgomery and colleagues [78] reported signi-
cant changes in TMJ and ear, neck, and shoulder pains, whereas headaches
were changed less consistently following arthroscopy of the TMJ.
Summary
Much can be learned by trying to identify and understand pain mecha-
nisms and apply current therapeutic options based on these concepts. This
allows a broad approach to an often complex and challenging problem.
Our primary goal must be to alleviate the pain and suering that our
patients who have head, neck, and facial pain experience. Therefore, we
are obliged to approach pain management using all of the therapies at
our disposal, with specic care not to worsen the situation. Sometimes, ther-
apy can be aimed specically at the source of nociception; however, in
chronic situations, dealing with behavior and suering may be more impor-
tant than altering the nociception. To this end, all clinicians are encouraged
to understand the mechanisms that cause pain, and to remember that at-
tached to every joint and nerve is a human being.
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Dent Clin N Am 51 (2007) 145160
Psychological Factors Associated

with Orofacial Pains
Charles R. Carlson, PhDa,b,*
a
Department of Psychology, 106 Kastle Hall, University of Kentucky, Lexington,
KY 40506-0044, USA
b
Department of Oral Health Science, 106 Kastle Hall, University of Kentucky, Lexington,
KY 40506-0044, USA
This article develops the case for why trigeminal pain is a unique and
challenging problem for clinicians and patients alike, and provides the
reader with insights for eective trigeminal pain management based on an
understanding of the interplay between psychologic and physiologic sys-
tems. There is no greater sensory experience for the brain to manage than
unremitting pain in trigeminally mediated areas. Such pain overwhelms con-
scious experience and focuses the suering individual like few other sensory
events. Trigeminal pain often motivates a search for relief that can drain -
nancial and emotional resources. Therefore, it is not uncommon for individ-
uals to spend hundreds, if not thousands, of dollars in the quest for quieting
trigeminal pain. In some instances, the search is rewarded by a treatment
that immediately addresses an identiable source of pain (eg, appropriate
endodontic treatment for an infected tooth). In other cases, however, it
can stimulate never-ending pilgrimages from one health provider to another
in the hopes of nding some relief for unrelenting trigeminal pain. Ongoing
trigeminal pain demands attention and can prevent an individual from living
any semblance of a normal life.
When trigeminal pain is present, it is dicult for the individual to imag-
ine why pain could ever be a good thing. In fact, it is not uncommon for
practitioners and patients alike to view trigeminal pain, or any pain for that
matter, as the enemy; it is something to be fought against and abolished by
excision, ablation, medication, or someday perhaps, even gene therapy.
There are some people, however, who suer greatly because they do not
* Department of Psychology, 106 Kastle Hall, University of Kentucky, Lexington, KY

40506-0044.
146 CARLSON
have the ability to experience pain. Individuals who live with leprosy must
learn to deal with life without the benet of pain sensations from peripheral
tissues. The bacillus that causes this infection that much of the world knows
as Hansens disease, destroys the nervous tissue that is responsible for
transmitting nociceptive information to the brain. A person who has leprosy
does not have access to normal pain sensations to tell her/him that a wrinkle
in the leather of a sandal is rubbing a blister on the sole of the foot with each
footstep. It was not too long ago that health care providers learned that the
digit loss that often is associated with leprosy came from rodents gnawing at
exposed ngers and toes while the sleeping person was unaware of noxious
sensory experience, and not from the leprous disease process itself. Life
without pain sensations can present its own special challenges.
A few years ago, Dr. Paul Brand, MD, an English orthopedic surgeon,
obtained a research grant to develop an articial pain glove for persons
with leprosy so that they could protect themselves from exposure to exces-
sive tissue-damaging pressures while they worked with their hands. After
much eort to develop the appropriate algorithms for combining force of
pressure and duration of pressure together, the research group perfected
an articial glove system that signaled when excessive pressure over time
was being applied and there was danger for tissue damage. What surprised
the researchers was that those using the articial gloves would ignore the au-
dible signals and persist in performing an activity even though they knew
what they were doing was tissue damaging. In hopes of rectifying the situa-
tion, the researchers redesigned the signaling system so that instead of using
an audible warning, the gloves were xed to send a small electrical impulse
to the axilla region, one of the more sensitive areas of the human body. The
researchers found that when the persons who had leprosy were engaged in
work that created the potential for tissue damage, they turned this modied
signaling system o, rather than changed their work habits. This experience
challenged Brands research group, and reminded them that pain is an im-
portant biologic signal. It is not surprising that access to the pain o but-
ton is dicult to obtain. It is, however, conceivable that if one had the
capacity to turn natural pain systems o, it likely would lead to personal
harm rather than benet, because the pain system would be shut down in
pursuit of reward from work, even though the excessive usage might cause
personal injury.
Given the importance of pain signaling systems, it is now useful to focus
on the psychologic issues that are associated with trigeminal pain systems so
that the reader can develop an appreciation for why trigeminal pain can be
such a management challenge for practitioners and patients alike. Several
unique features of trigeminally mediated pain will be integrated with recent
scientic ndings. The intent of the remainder of this article is to develop
a broad framework for understanding the psychologic issues that may be
present in those who seek help for trigeminal pain, and use this understand-
ing to guide the development of more eective treatments.
PSYCHOLOGICAL FACTORS & OROFACIAL PAINS 147
Several research groups have identied the frequency with which psychi-
atric disorders have been diagnosed among persons who have orofacial
pain. For example, Korszun and colleagues [1] found that 28% of patients
who have chronic pain meet criteria for the diagnosis of depression. Kight
and colleagues [2] noted that 31% of patients who had orofacial pain
were experiencing anxiety disorders. Consideration of psychologic distress,
therefore, is an important factor to consider in the initial evaluation of a pa-
tient who has orofacial pain. Rugh and colleagues [3] suggested that general
practitioners could use two screening questionsdHow depressed are you?
and Do you consider yourself more tense than calm or more calm than
tense?dto identify patients who have orofacial pain and ought to be re-
ferred to a mental health provider for further evaluation. Any response
that indicates awareness of depression or more tension than calmness indi-
cates a need for further psychologic evaluation.
An alternative to brief screening questions is to use standardized psycho-
metric instruments to take advantage of the use of actuarial information-
gathering strategies. These actuarial strategies enable the clinician to
compare an individual patients results with standardized normative data
and make judgments based on statistical inferences rather than clinical obser-
vation alone. The Research Diagnostic Criteria (RDC) Axis II [4] uses the
somatization and depression scales of the Symptom Checklist 90 revised
(SCL-90R) [5] to assist the clinician in evaluating the role that psychologic
factors may play in a patients ongoing experience with pain. At the Univer-
sity of Kentucky Orofacial Pain Center, the entire SCL-90R is used to provide
a comprehensive review of psychologic symptoms for individual patients who
have orofacial pain, in addition to gathering the data needed for RDC deci-
sions. For pain assessment, the MultiDimensional Pain Inventory [6] can pro-
vide the clinician with a comprehensive review of the intensity and impact of
pain for the individual patient. Alternatively, the RDC makes use of a 0 to 10
linear pain scale and the Graded Chronic Pain Scale to index pain severity
and pain-related life interference. The important point here is that there are
many means by which to evaluate carefully the psychologic status of patients
who have orofacial pain, and systematic attempts should be made to assess
psychologic status as the standard of care with every patient.
One of the interesting psychologic ndings that is emerging recently is the
extent to which persons who have orofacial pain may be carrying the marks of
exposure to trauma [7]. Several years ago, Curran and colleagues [8] found
that a signicant number (67%) of patients who had orofacial pain reported
on an anonymous survey that they had experienced physical or sexual abuse.
Sherman and colleagues [7] conducted comprehensive diagnostic interviews
among patients who had orofacial pain. They found that one in four patients
met criteria for the lifetime experience of posttraumatic stress disorder
(PTSD). Diagnostic criteria for PTSD include (1) exposure to threat to self
or others with a response of fear, helplessness or horror; (2) persistent re-
experiencing of the traumatic event through memories, dreams, ashbacks,
148 CARLSON
or symbolic events; (3) persistent avoidance of stimuli that remind one of the
trauma and numbing of general responsiveness; (4) persistent symptoms of
increased arousal that include sleep dysfunctions, anger outbursts, and hyper-
vigilance; and (5) the symptoms have a duration of greater than 1 month and
cause signicant distress and impairment of functioning. PTSD has an inordi-
nately high co-occurrence with orofacial pain conditions; the clinician needs
to be sensitive to the possibility that it may be interfering with a patients abil-
ity to manage an orofacial pain condition.
Several years ago, Gatchels research group reported that almost one of
every three patients who have orofacial pain and present in an orofacial pain
clinic have a diagnosable personality disorder [2]. A personality disorder is
an enduring pattern of behavior that does not conform to normal standards.
For example, the person who has an antisocial personality disorder does not
believe that the rules of society apply to her/him. The person who has bor-
derline personality disorder struggles with establishing and maintaining
adequate boundaries. In the orofacial pain practice, this can be seen in
a situation where a patient is overly reliant on late night phone calls to
the health care provider and seems not to be aware of their intrusive nature.
Although it is dicult to diagnose personality disorders without an exten-
sive structured clinical interview, the orofacial pain clinician should be sen-
sitive to the possibility that dicult patients may be dicult because of
enduring personality issues that can interfere with the eective delivery of
care.
Biopsychosocial model and features of orofacial pain

The interplay between psychologic and physical functioning is communi-
cated by the biopsychosocial model. This perspective provides for a broad
understanding of the biologic, psychologic, and sociologic contexts that
are associated with a person who is experiencing a physical or emotional dis-
order [9]. The biopsychosocial perspective takes into account the interplay
among these various systems and helps to provide an organizing construct
for the multiple information sources that are relevant to understanding
a pain condition. Complex orofacial pain conditions generally do not repre-
sent a simple, linear cause and eect model. Rather, these conditions, par-
ticularly when chronic, demonstrate the complex interplay among biologic
and behavioral systems that are constantly in a state of change. Therefore,
the orofacial pain clinician must take into account the multiple interacting
factors that inuence a patients ongoing pain state. The biopsychosocial
model is a tool that helps the clinician to implement this perspective.
Foremost within the biopsychosocial perspective is appreciating the bio-
logic factors that contribute to the pain experience. These factors include,
among other things, genetics, tness level, nutritional status, autonomic bal-
ance, and allostatic load. Allostatic load refers to the physical stress on an
individual from repeated physiologic activation and inhibition that comes

from responding to life stressors. Pain can be inuenced by a variety of bi-
ologically based variables; the pain clinician needs to ensure a careful review
of biologic factors during the initial evaluation. Biomedical assessment strat-
egies that include a physical examination, laboratory tests, and diagnostic
imaging are important tools for the clinician to use in developing a biologic
perspective on the patients who present complaints.
It also is important to review behaviors or psychologic factors that may
be contributing to the pain experience as well. Ohrbach [10] has rightly
noted that treatments that fail to take into account the behavioral and psy-
chologic factors that are associated with orofacial pains likely will not work
reliably. Therefore, behavioral factors that include principles of learning (eg,
reinforcement, punishment, modeling, discrimination), interpersonal pro-
cesses, inhibitory control (eg, relaxation skills, delay of gratication), and
cognitive regulatory strategies (eg, goals, expectations, plans) need to be as-
sessed as a part of the initial evaluation. The treatment plan must take into
account the multiple biologic and behavioral (biobehavioral) systems that
can contribute to the development and maintenance of orofacial pains.
Therefore, the astute clinician will use a careful psychosocial interview
and diagnostic psychologic questionnaires to help form the database for
comprehensive behavioral assessments of patient behaviors that may be
contributing to the presenting complaints.
It is helpful to keep in mind that the assessment of pain in the trigeminal
area needs to be informed by the importance that is attached to the meaning
of pain in this region. Because the head region contains structures that are
necessary for survival (eg, mouth, nose), pain in this region can be perceived
as a threat to survival. Further, these orofacial structures also are conduits
for giving and receiving pleasure. Pain in orofacial structures can limit an
individuals ability to receive pleasurable stimuli or to deliver such stimuli.
It is not uncommon for patients to eschew kissing or any form of touching
in the face when trigeminal pain is active. The same structures represent
a prime communication system and pain can threaten an individuals ability
to communicate. Therefore, pain in the orofacial region may involve unique
psychologic interpretations that the clinician needs to be sensitive to and ac-
count for in treatment planning and delivery.
There are excitatory and inhibitory factors in pain modulation that
should inform the diagnosis and treatment of orofacial pain conditions. Ex-
citatory factors, or those factors that can enhance pain sensitivity, include
attention, expectancies for pain (eg, this pain is something youll have
for the rest of your life), anxiety, fear, and anger. Recently, a graduate stu-
dent in the authors research laboratory conducted a functional MRI study
of how anger and fear inuence activation in brain centers that are respon-
sible for trigeminal pain experience [11]. His results indicated that pain, an-
ger, and fear are processed in similar regions in the brain; anger, especially,
increases the activity of brain regions that are responsible for processing
150 CARLSON
trigeminal pain. It is not unusual for patients who have orofacial pain to re-
port signicant levels of anger. The clinician must be willing to explore the
nature of a patients anger experience if an eective treatment plan is to be
developed and implemented. The astute clinician is aware that attention, ex-
pectancies, and ongoing emotional states can increase an individuals aware-
ness and self report of pain.
Conversely, pain sensitivity can be reduced by such factors as condence,
self-ecacy (beliefs about ones ability to manage pain successfully), assur-
ance, distraction, relaxation, and positive emotional states. Several years
ago, the authors laboratory, for example, published data indicating that
positive emotional states (eg, happiness) and brief relaxation procedures
could reduce pain sensitivity in individuals who were exposed to a standard
pain stressor [12]. Furthermore, there is ample evidence that relaxation
strategies, including progressive relaxation training, postural relaxation,
and breathing entrainment, can be used eectively to manage orofacial
pain conditions [13]. It is important to recognize and incorporate strategies
that can mitigate pain experience in the development of a comprehensive
pain management program.
It is said often that patients who have pain are just more sensitive to
painful stimulation than are pain-free individuals. Although there are
data suggesting that patients who have pain are more sensitive to painful
stimulation in trigeminal regions [14] and to ischemic pain stimulation in
the forearm [15], it is also true that patients who have pain are no more sen-
sitive than are pain-free individuals when experiencing pressure pain in non-
trigeminal areas (eg, hand) [16]. It would be a mistake to conclude that
patients who have pain generally are more sensitive than are pain-free indi-
viduals, but it also would be incorrect to say that patients who have trigem-
inal pain are not more sensitive to certain kinds of sensory stimulation,
particularly in trigeminal areas. It is well known that pain heightens sensi-
tivity in painful regions and can cause reexive modications in function
to protect the individual from further provocation from pain and tissue
damage that are associated with inappropriate movements. The orofacial
pain clinician needs to be aware of heightened pain sensitivity, but should
be careful not to ascribe that sensitivity to inherent mental or physical de-
ciencies in the individual patient.
Fatigue is one of the common symptoms that is reported by many pa-
tients who have pain. In fact, the painfatiguesleep disturbance triad is rep-
resented in most individuals who seek care for chronic orofacial pain
conditions. Fatigue can be viewed as the perception of tiredness, rather
than as the true inability to do work. When it is not possible to perform
physical work because the muscles will not carry out the required actions,
the problem typically is described as peripheral fatigue. Central fatigue,
on the other hand, is a perception of tiredness that may not necessarily be
accompanied by physical fatigue in the working muscles. It is interesting
to speculate on the role that the perception of fatigue may play among
patients who have orofacial pain. The author and colleagues [14,17] have
found that patients who have orofacial pain report greater fatigue than
do those who are not in pain. Although the nature of this fatigue (central
or peripheral) is not clear for patients who have orofacial pain, many pa-
tients report experiencing debilitating levels of fatigue; strategies to address
this problem should be discussed in the treatment plan.
It is natural to consider the importance of sleep variables at this point in
the discussion. Most patients who have pain report disturbed sleep at some
level [14,18]. The nature and extent of disturbed sleep can be assessed quan-
titatively using the Pittsburgh Sleep Quality Index [19]. This instrument pro-
vides a psychometrically sound method for assessing sleep onset, duration,
and quality. Because sleep typically is initiated when brain activity dimin-
ishes, one way to conceptualize sleep disturbances in patients who have
pain is failure of the brain to quiet to the point that sleep is initiated. More-
over, frequent awakenings that are reported by patients who have pain sug-
gest that arousal regulatory mechanisms are disturbed. Lavigne and
colleagues [20] discussed the role of sleep disturbance in orofacial pain
and recommended that treatments to restore sleep be a part of a comprehen-
sive pain management plan. Recently, an National Institutes of Health con-
sensus panel concluded that relaxation training is useful in helping patients
who have chronic pain to initiate and maintain sleep [21]. These ndings are
consistent with conceptualizing the sleep problems for patients who have
pain as a failure of the brain to quiet (lack of inhibitory control). Thus,
patients who have orofacial pain may obtain signicant sleep benets
from learning specic relaxation skills.
Persistent stressorsdand certainly, unremitting pain can be considered
a persistent stressordinvolve prolonged activation of the reticular forma-
tion in the brain and subsequent regulatory control of glucose and ATP
availability, oxygen and carbon dioxide levels, motor unit recruitment to
perform work, and release of endogenous opioids (eg, b endorphin) for com-
pensatory inhibitory control. When these systems experience long-term de-
mands, eective function may be compromised and inecient anaerobic
metabolism may develop; respiratory changes may lead to subtle alterations
in blood pH that can aect axonal excitability and sympathetic nervous sys-
tem activation; myoelectric frequency shifts in muscle activity occur as mo-
tor units fatigue; and endogenous opioids have diminished eectiveness for
quieting physiologic systems. These changes can lead to dysregulation of the
autonomic nervous system and heighten the experience of pain, sleep disrup-
tions, and negative aect (anxiety, fear, anger) that are common in chronic
orofacial pain conditions.
Although increased autonomic activation is a normal adaptive mecha-
nism for managing life stressors, heightened emotional and physical respon-
sivity is characteristic of a chronic defense reaction in the presence of
relentless stressors [22,23]. Prolonged stimulation from nociception, for
example, is known to be one of the most signicant activators of the
152 CARLSON
sympathetic nervous system; it can be viewed as an important endogenous

stressor itself [24]. Recent evidence showed that when primary nociceptors
are stimulated by tissue damage, activity by collateral nonnociceptive
peripheral neurons further increases the rate of activity from those nocicep-
tors [25,26]. Even in nonpain situations, anxiety-induced autonomic activity
that alters carbon dioxide levels may cause ectopic impulses to be generated
from dense receptive elds within the trigeminal region [27]. Under condi-
tions that promote central sensitization, sympathetic activity from a variety
of stimuli may have signicant eects on nociceptive interpretation or sub-
sequent pain reports [28]. Therefore, management of dysregulated auto-
nomic activity can be regarded as an important treatment goal for
persons who have pain disorders, although it may not be clear whether
the altered autonomic activity is a causative factor or a consequence of
the pain experience [29].
Recently, it was noted that the complex integration of central and auto-
nomic nervous system functioning can be indexed by vagally mediated heart
rate variability (HRV) [30,31]. The HRV measure serves as a marker for the
negative feedback that is conveyed to the heart by way of the vagus nerve
that is important for self-regulation and ecient cardiovascular perfor-
mance through control of cardiac rate and electrical conduction speed.
The vagus nerve primarily exerts tonic inhibitory control of the cardiovas-
cular system [31]. Although HRV represents the changes in beat-to-beat in-
terval over time, it is evaluated commonly by spectral analyses whereby
heart rate data are transformed from the time domain (beat-to-beat inter-
vals) to the frequency domain (oscillations). Typically, these transforma-
tions are done with Fast Fourier analyses, such that the high-frequency
(0.150.4 Hz) component of the power spectrum density of HRV reects pri-
marily parasympathetic activity linked to respiration rate (respiratory sinus
arrhythmia), the low-frequency component (0.050.15 Hz) is a combination
of sympathetic and parasympathetic activity, and a very lowfrequency
component (0.0050.05 Hz) relates to sympathetic mediation of vascular
tone and body temperature [3234]. Moreover, the ratio of the low-fre-
quency to high-frequency components of HRV data is believed to represent
primarily sympathetic activity, although there is not uniform agreement on
this interpretation. The meanings of HRV measures and the complexity of
cardiac regulatory processes are still being elaborated. Porges [35] for exam-
ple, noted that autonomically mediated modulatory controls are not always
similar to tonic autonomic controls, as is illustrated by the uncoupling in
cardiac regulation that occurs during the orienting reex when there is a va-
gally controlled decrease in heart rate accompanied by a pause in respiratory
sinus arrhythmia.
In normal individuals, HRV is high and an indication of positive health
status, with well-regulated sympathetic and parasympathetic functioning
[31]. Reduced HRV, however, has been associated with a broad range of
dysfunctional states, including heart disease, obesity, gastrointestinal
esophageal reux disease, irritable bowel syndrome, mood disorders, and

anxiety disorders [31,36,37]. It also has been shown that HRV can be en-
hanced by behavioral strategies that include relaxation and paced breathing
[3840]. Recently, John Schmidt [41] conducted a study in the authors lab-
oratory that compared HRV measures during rest and recall of a personally
relevant stressor between patients who had orofacial pain and matched nor-
mal controls. He found that patients who had orofacial pain demonstrated
an increase in sympathetic tone and less HRV than did matched controls;
however there are no known studies of HRV after treatment, in persons
who have orofacial pain conditions. Further examination of this potentially
important physiologic variable in a population that has orofacial pain may
shed light on its usefulness as an index of allostatic load, as well as treatment
outcome.
Sustained activation of autonomic and hypothalamicpituitaryadrenal
(HPA) axis functioning may have signicant negative consequences. With
an increase in HPA axis functioning under acute stress, the principal stress
hormone that is releaseddin addition to epinephrine and norepinephrined
is cortisol. Cortisol is secreted by the adrenal cortex as a result of release of
adrenocorticotropin hormone from the pituitary gland [24]. Cortisol is
known to inuence glucose metabolism, immune function, and tissue repair.
Recent evidence indicated that persons who experience rheumatoid arthritis
[42], primary bromyalgia syndrome [43], PTSD [44], and chronic pain [45]
have decreased cortisol levels, presumably as a consequence of prolonged
physiologic activation. These ndings have been interpreted to suggest
that normal HPA function is disrupted under conditions of prolonged stress
within certain patient groups.
Generally, cortisol levels demonstrate substantial uctuation during the
course of a 24-hour period, and for women there also are changes over
the 28-day menstrual cycle. It has been shown, however, that the increase
in cortisol levels within the 60 minutes after awakening follows a highly re-
liable pattern for most individuals that is not related to age, weight, smok-
ing, sleep duration, time of awakening, and alcohol usage [46,47]. The free
cortisol response to awakening is assessed by sampling salivary cortisol
levels immediately after waking and at 15-minute intervals for the rst
hour after awakening. This measure has demonstrated reliability as a bio-
logic marker for adrenocortical activity. Geiss and colleagues [45], for exam-
ple, found that persons who had persistent back and leg pain had lower
overall cortisol concentrations and a blunted free cortisol response to awak-
ening as compared with healthy pain-free controls. Moreover, they found
that the concentration of interleukin-6, a proinammatory cytokine, was in-
creased in the group that had chronic pain. Recent data from the authors
laboratory indicate that patients who have chronic orofacial pain also ex-
hibit blunted free cortisol responses to awakening [48]. These data are con-
sistent with the hypothesis that chronic pain conditions alter HPA function
in a manner that may impede tissue repair and recovery, as well as promote
154 CARLSON
heightened sensitivity to environmental challenges or stimuli, whether gen-

erated from the outside environment or internally, by the individual.
One common view among patients and practitioners is that orofacial
pain conditions, particularly those that involve muscles of mastication,
are accompanied by increased muscle activity in those muscle groups. In
fact, several research teams have identied low levels of increased muscle
activity as characterizing individuals who have masticatory muscle pain
conditions [49]. There is alternative evidence, however, to suggest that ex-
cessive muscle activity does not characterize muscle pain conditions in the
orofacial region [14,16,50]. Although it can be demonstrated that pain al-
ters muscle function, it is not wise to make a generalization to an individ-
ual patient without objective data that quantify the nature of the muscle
activity.
There are data, however, suggesting that the physiologic overactivity in
patients who experience chronic muscle pain in the muscles of mastication
can alter two measurable parameters [14]. These parameters include resting
diastolic blood pressure and end-tidal carbon dioxide levels. These ndings
suggest that chronic muscle pain, at least, may lead to decreased diastolic
blood pressure because of pooling in vascular capillary beds. It is well
known in the cardiovascular literature that chronic stress can result in
poor venous return because of the capillary pooling. The nding that pa-
tients who have chronic muscle pain have decreased diastolic blood pressure
is consistent with a chronic stress hypothesis.
The lower end-tidal carbon dioxide levels in patients who have pain, as
compared with matched controls, also can be explained based on a chronic
stress reaction. Respiration rate and depth can change automatically when
there is a stress reaction. In the case of chronic pain, because there typically
is limited physical activity when the respiration rate increases as a natural
response to the sympathetic activation from the pain, the ventilation of car-
bon dioxide occurs without compensatory production of carbon dioxide in
body tissues. Therefore, the concentration of carbon dioxide decreases in the
serum. Because carbon dioxide levels in the blood are directly proportional
to the concentration of carbon dioxide in expired air, there are lower end-
tidal carbon dioxide levels at rest in patients who have pain than in matched
normal controls.
The implications of lower end-tidal carbon dioxide levels in patients who
have pain are potentially far-reaching. Carbon dioxide is necessary to main-
tain blood pH through the bicarbonate buer. Lowered concentrations of
carbon dioxide can result in slightly elevated pH levels (7.57.6) from the
bodys normal level of 7.4. Such increases can result in further increases
in sympathetic tone, increased neuronal excitability, reduced peripheral
blood ow, and impaired dissociation of oxygen from hemoglobin [51].
Thus, restoration of normal carbon dioxide levels in serum is a potentially
important behavioral intervention target to achieve in patients who have
chronic orofacial pain.
Biobehavioral approaches to orofacial pain management

The remainder of this article is devoted to introducing behaviorally based
strategies for helping patients develop better management of their pain. The
phrase management of their pain was selected intentionally because it
underscores the importance of using pain as an important biologic signal
that something is disturbed. The basic premise is that when pain is
perceived, there is a physiologic disturbance that needs attention, whether
it be in peripheral tissues or in the brain itself. Unless the physiologic
disturbance is attended to, the pain will remain. Importantly, the patients
pain is interpreted as real. It is not something that is manufactured, but
rather represents an important reection of an individuals perception.
When a health provider accepts the reality of anothers perception it builds
trust in the therapeutic relationship and fosters the working alliance. The
management approach also focuses on the reality that pain of a chronic
nature often is not cured or taken away permanently. Rather, pain is
managed eectively so that an individual can engage life to the fullest.
The management approach often requires an individual to change. The
process of change can be dicult, yet understanding how people change is
important for the orofacial pain provider. There is a ve-step process of
change that has been developed in the literature [52]. The rst step in the
process is described as precontemplation. In the precontemplation phase
the individual is not aware of a need for change, but when an awareness is
developed s/he has moved to the stage of contemplation. During this phase
an individual is weighing the costs and benets of change for themselves.
The third stage of change is preparation for taking action. The individual
is taking the steps necessary to make a successful attempt at change. The
fourth step is action, whereby the individual implements the new behaviors.
The fth change stage is maintenance, during which the individual is doing
those things that are necessary to continue with the changes that were imple-
mented in the fourth stage. Consideration of each of these stages of change
helps the orofacial pain clinician appreciate the challenges that a patient faces
when confronted with information that suggests s/he may need to change in
some way to obtain pain relief.
One of the important messages of behavioral research over the past
several decades is that helping individuals change is fostered by brief
interventions and change talk. There are many examples of the eectiveness
of brief interventions. For instance, Holroyd and colleagues [53] developed
an eective approach to migraine headache treatment that involves minimal
therapist contact and primarily home-based interventions. Similarly,
Chapman and Huygens [54] demonstrated that brief therapy for alcoholics
was just as eective as was a long-term (6 weeks) intensive treatment pro-
gram for reducing drinking behavior. In orofacial pain, brief interventions
also were shown to be eective in reducing pain for signicant periods of
time [13,55]. The Physical Self Regulation (PSR) program that was
156 CARLSON
developed jointly by scientist-practitioners at the University of Kentucky

and the National Naval Dental Center provides skills training for orofacial
pain management during two 50-minute training sessions. These sessions
target proprioceptive re-education, relaxation skills, criterion-based dia-
phragmatic breathing, increased physical activity, sleep hygiene instructions,
and uid/nutrition management as areas for change. These treatment do-
mains were based upon laboratory research ndings [14,50] and were shown
to provide signicant relief of pain (average of 69% reduction in self-report
of pain) and improved jaw functioning immediately after training and at
6-month follow-up evaluations [13]. The eectiveness of the PSR training
has resulted in it becoming the standard baseline treatment for many pa-
tients who have chronic orofacial pain. The bottom line for this discussion
is that important and meaningful change can occur following brief interven-
tions. Elaborate and lengthy interventions are not necessary for signicant
change to take place in the lives of individuals who are ready to change.
The clinician can help the patient to change by encouraging her/him to
engage in change talk. Typically, change talk involves three components.
The rst component is enabling the individual to speak about the disadvan-
tages of his/her current status. The second component is to have the individ-
ual speak about the advantages of making a change. Finally, the third
component of change talk is helping the individual to express specic inten-
tions to change. The clinician who fosters change talk will discover that an
individual becomes much more willing to begin the process of change and
will persist in eorts to change until old habits have been altered. When
change talk is accompanied by a clinicians use of empathic listening where
a patient feels like s/he is truly understood, a patients capacity to mobilize
resources for change is engaged most fully.
Ideally, specic biobehavioral strategies for orofacial pain conditions
should follow a stepped approach to self-regulation training. This stepped
approach is patterned after the stepped-care strategies that are used to ad-
dress common medical conditions (eg, hypertension). The rst, or founda-
tional step, is ensuring basic skills in PSR or self-care strategies. The basic
protocol for PSR establishes a foundation for understanding and regulating
behaviors that can contribute to trigeminally mediated pain conditions.
There are many individuals for whom home PSR training alone provides
the necessary skills for eective pain management. Advanced progressive re-
laxation or biofeedback strategies can build upon this basic foundation as
the second level of biobehavioral training. Training in progressive relaxation
techniques [56] or specic biofeedback modalities (ie, electromyography for
muscle relaxation, end-tidal carbon dioxide training to control carbon diox-
ide levels in the blood, hand temperature training to increase blood ow to
peripheral areas) can augment basic self-regulation abilities that are ob-
tained through PSR training. The third level, or step, of biobehavioral train-
ing can be engaging in specic cognitive-behavioral psychotherapies to
address issues, such as depression, PTSD, or other psychologic concerns,
that may be interfering with normal functioning and contributing to the

maintenance of a chronic pain state. The use of a stepped approach in bio-
behavioral strategies can maximize the eciency with which persons in pain
develop the resources that are needed to improve their ability to manage
their pain experience more eectively.
When the orofacial pain clinician recognizes the need for referral to other
health professionals for biobehavioral training that s/he cannot provide, it is
important to develop a strategy for making the transition to another health
provider successfully. Often when a dental practitioner makes a referral to
a psychologist for biobehavioral training, unless the dental practitioner ex-
ercises care in what is said, the patient can misconstrue the intentions of the
dental practitioner. It is not uncommon for patients to infer from the refer-
ral that the dentist thinks my pain is not real and it is all in my head. To
reduce the likelihood for this to occur, it may be helpful to use the words
stress management when talking about the need for a biobehavioral con-
sultation with a patient. Most persons are more comfortable with the idea of
seeing another health provider for a stress management consultation than
because there are questions about ones psychologic status. There are times,
however, if the dental clinician has a signicant concern about the level of
depression or anxiety, that direct communication with the patient about
concerns for her/his welfare as the reasons for the referral to another health
provider will be most eective in helping that patient make a successful tran-
sition to the new health provider. It is useful if the dentist take the initiative
to set the appointment and helps to ensure that the patient follows through
with the visit to the biobehavioral training specialist. Successful referrals for
biobehavioral training require an adroit dental practitioner who has estab-
lished strong working relationships with competent specialists who are
skilled in delivering biobehavioral interventions.
Summary
This article has provided a broad overview of the unique psychologic and
physiologic issues that are associated with the management of orofacial pain
conditions in general. Trigeminal pain problems can be vexing challenges for
patient and clinician alike. Even the most skilled clinicians can be put to the
test with unusual trigeminal pain presentations. Fortunately, many acute or-
ofacial pains can be managed in a straightforward manner and full remis-
sion of the pain symptoms can be achieved. There are, however, some
chronic orofacial pains that result in a varying clinical course, particularly
when the underlying cause is unknown. The biobehavioral perspective can
be an important guide in helping patients who have chronic pain presenta-
tions come to understand their conditions and learn to manage them more
eectively while they are receiving competent dental care. The ideal profes-
sional model is for the biobehavioral approach to be an essential component
158 CARLSON
of the standard care that a patient who has orofacial pain receives. The in-
tent of this article is to lay a foundation for dental practitioners to integrate
biobehavioral perspectives routinely into their delivery of orofacial pain
interventions.
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Dent Clin N Am 51 (2007) 161193
Temporomandibular Disorders, Head

and Orofacial Pain: Cervical Spine
Considerations
Steve Kraus, PT, OCS, MTC
2770 Lenox Road, Suite 102, Atlanta, GA 30324, USA
Head and orofacial pain originates from dental, neurologic, musculoskel-

etal, otolaryngologic, vascular, metaplastic, or infectious disease and is
treated by many health care practitioners, such as dentists, oral surgeons,
and physicians, who specialize in this pathology. This articles focus relates
to the nonpathologic involvement of the musculoskeletal system as a source
of head and orofacial pain. The areas of the musculoskeletal system that are
reviewed include the temporomandibular joint (TMJ) and muscles of mas-
ticationdcollectively referred to as temporomandibular disorders (TMDs)
and cervical spine disorders [1].
Often, conservative treatment is recommended for most patients who ex-
perience TMDs and cervical spine disorders [1,2]. Physical therapists oer
conservative treatment in rehabilitation of TMDs and cervical spine disor-
ders. The American Physical Therapy Association (APTA) denes physical
therapy as . the care and services provided by or under the direction and
supervision of a physical therapist. [3]. The position of the APTA is .
only physical therapists provide or direct the provision of physical therapy
[4]. The most valuable contribution that physical therapists make regarding
the management of TMDs and cervical spine disorders is in the proper iden-
tication of the components in the musculoskeletal system that contribute to
a patients symptoms and functional limitations. This is done by collecting
a detailed history from the patient and conducting an appropriate physical
assessment based on the history [4]. A properly performed evaluation by
a physical therapist determines the type of treatment oered, and results
in optimal and meaningful functional outcomes.
Consequently, the validity of research that investigates physical therapy
interventions for TMDs and head and orofacial pain should be questioned
162 KRAUS
when it is unclear if a physical therapist participated in the evaluation of the

patient or provided physical therapy treatment. Referring to physical ther-
apy as only a modality is misleading, and conclusions made about the ther-
apeutic value of physical therapy may be inaccurate [5,6]. The objective of
this article is to demonstrate the extent to which a physical therapist who
is trained in the specialty of TMDs and cervical spine disorders contributes
to the successful management of this condition.
The rst part of this article highlights the role of physical therapy in the
treatment of TMDs. The second part discusses cervical spine considerations
in the management of TMDs and head and orofacial symptoms. The article
concludes with an overview of the evaluation and treatment of the cervical
spine.
Physical therapy management of temporomandibular disorders

TMD is divided into arthrogenous disorders, which involve the TMJ,
and myogenous disorders, which involve the muscles of mastication [1].
An extensive subclassication for arthrogenous and myogenous disorders
exists [1]. The common arthrogenous and myogenous disorders that are
seen clinically by physical therapists, dentists, oral surgeons, and physi-
cians are addressed in this article (Box 1). The diagnostic criterion for
each of the common TMD conditions that follows is referenced in the
literature and is not covered in this article [1,79]. The objective of this
portion of the article is to highlight physical therapy treatment for
common TMDs.
Box 1. Common temporomandibular disorders

with corresponding International Classification of Diseases,
Ninth Revision (ICD-9) codes
TMD arthrogenous
Inflammation 524.62
Hypermobility 830.1
Fibrous adhesions 524.61
Disc displacements 524.63
Disc displacement without reduction
Chronic disc displacement without reduction
TMD myogenous
Masticatory muscle pain 728.85
CERVICAL SPINE CONSIDERATIONS 163
Temporomandibular disorders: arthrogenous

Inammation
Inammation can originate from TMJ tissues, such as the capsule, me-
dial, and lateral collateral ligaments, TMJ ligament, or posterior attach-
ment. TMJ tissue inammation can result from blunt trauma and
microtrauma that are caused by parafunctional activity. Parafunctional
activity is nonfunctional activity, which, when in the orofacial region, in-
cludes nail biting, lip or cheek chewing, abnormal posturing of the jaw,
and bruxism [1]. Bruxism is diurnal or nocturnal clenching, bracing, gnash-
ing, and grinding of the teeth [1] Inammation also can result from arthritic
conditions.
Physical therapy treatment for TMJ inammation involves patient educa-
tion regarding dietary and oral habits [9]. Iontophoresis, phonophoresis,
and interferential electric stimulation are therapeutic modalities that are
used to decrease TMJ inammation [1012]. Patients who are diagnosed
with TMJ inammation may have altered mandibular dynamics that are
due to intracapsular swelling and resultant joint pain. Physical therapists
teach patients range of motion exercises that maintain functional mandibu-
lar dynamics during the rehabilitation phase without causing more
inammation.
Hypermobility
Hypermobility is excessive translation of the mandibular condyle during
opening of the mouth [13]. With condylar hypermobility, the condyle trans-
lates anteriorly during opening following the slope of the articular eminence
past the articular crest onto the articular tubercle [13]. Hypermobility that
occurs unilaterally may be associated with deviation of the mandible, which
is observed during mouth opening. Deviation is the mandible moving away
from midline, but returning to midline at the end of opening [9]. Although
hypermobility may cause disc displacement of the TMJ, the cause and eect
relationship has not been established [14,15]. Hypermobility is a common,
and, frequently, benign, condition.
Patients who exhibit hypermobility without pain do not require treatment
[14]. Controlling hypermobility is necessary only when other TMJ condi-
tions exist. If the patient has TMJ inammation, hypermobility may perpet-
uate the inammation when the patient opens his/her mouth wide during
yawning. In the presence of TMJ inammation, full mouth opening, regard-
less of whether hypermobility exists, needs to be avoided.
Dislocation of the condyle can result from uncontrolled hypermobility.
Diagnosis of condylar dislocation is made if a patient complains that his
or her jaw catches on closing from a full, open mouth position. Hypermobil-
ity also may be accompanied by palpable joint noises. Palpable joint noises
are noises that are heard by the patient and felt by the clinician while palpat-
ing over the TMJ during opening and closing movements of the mandible.
Joint noises that are associated with hypermobility need to be dierentiated
164 KRAUS
from joint noises that are associated with a disc displacement. Although the
patient may not have pain with jaw movement, the experience of joint noise,
the feeling of a condyle catching on closing, and an awareness of deviation of
the mandible on opening are events that are disconcerting to the patient.
The most important aspect regarding treatment for hypermobility is pa-
tient education. Physical therapists should inform their patients that noises
and deviations of the jaw are not necessarily signs of signicant pathology,
and that they can be controlled with proper muscular re-education strate-
gies. When mouth closing is associated with catching, the amount of mouth
opening needs to be controlled through neuromuscular coordination exer-
cises that are taught by a physical therapist who is knowledgeable in exercise
interventions for TMJ hypermobility [9].
Disc displacement
Disc displacement can be classied into three stages: disc displacement
with reduction, disc displacement without reduction, and chronic disc dis-
placement without reduction [16]. Not all disc displacements are painful
or interfere with functional movements of the mandible. Treatment is neces-
sary when a patient experiences pain with or without functional limitations
of the jaw [17]. Treatment choices for disc displacements that are painful or
interfere with function consist of repositioning the disc to the condyle or al-
lowing the disc to remain displaced while improving the function and de-
creasing the pain in the intra-articular and associated periarticular/
myofascial tissues about the TMJ.
When choosing to reposition the disc to the condyle, the options are ar-
throtomy or an anterior-repositioning appliance. Because of the progressive
nature of disc displacement, which is accompanied by increasing pathologic
changes in the disc itself and its peripheral attachments, restoring a satisfactory
functional disccondyle relationship may be dicult [17]. Consequently, ar-
throtomy and anterior-repositioning appliances have led to mixed results in
maintaining a normal long-term disccondyle relationship [1822].
Arthrotomy is a treatment choice for patients who do not respond to con-
servative care. Conservative care consists of physical therapy, medication, and
a full-coverage acrylic appliance that does not reposition the mandible [23].
An anterior-repositioning appliance, which repositions the mandible, is
the most controversial treatment option for repositioning the disc to the
condyle [24]. The controversy relates to whether the anterior-repositioning
appliance actually recaptures the disc [24]. During the use of an anterior-
repositioning appliance, the absence of joint noises and pain with functional
mouth opening does not necessarily indicate that the disc has been recap-
tured [20,24]. Studies using pre- and post-CT and well as MRI showed
that permanent long-term disc recapture using an anterior-repositioning ap-
pliance was noted in only 10% to 30% of the patients [20]. When an ante-
rior-repositioning appliance is discontinued, some patients may require
orthodontics and possible orthognathic surgery. For the most part, an
anterior-repositioning appliance should be considered on a case-by-case ba-

sis, and only should be used as an infrequent treatment option for reposi-
tioning disc displacements [24].
If the choice is not to reposition the disc to the condyle, the treatment
options are arthroscopy (in its simplest format involving lavage/lysis), arthro-
centesis, and physical therapy. The therapeutic value common to arthros-
copy, arthrocentesis, and physical therapy interventions relates to the
facilitation of adaptive responses of the articular tissues to the disc displace-
ment. The human TMJ can adapt or remodel in response to articular disc dis-
placement, regardless of the type of intervention, and often best when there is
no intervention. For example, the posterior attachment of the disc (superior
and inferior stratum and retrodiscal pad) becomes a pseudo disc that can
withstand loading of the condyle during function [17,25]. Restoring a normal
disc position is not a necessary component for treating pain and functional
resolution [17]. Nonpainful disc displacements are so prevalent in patient
and nonpatient populations that they may be considered a normal anatomic
variability [2628]. Because adaptive responses of the articular tissues within
the TMJ are common secondary to disc displacementdand in most cases lead
to pain-free and functional outcomesdperhaps the most therapeutic inter-
vention should be the least invasive (ie, physical therapy).
Disc displacement without reduction

An article that has reviewed the literature comparing arthrocentesis, ar-
throscopic surgery, and physical therapy for the treatment of disc displace-
ment without reduction has demonstrated no signicant dierence in the
eects of maximum mandibular opening, pain intensity, or mandibular
function [29]. The decision to perform arthroscopy or arthrocentesis
instead of physical therapy should be based upon an evidence-based evalu-
ation as well as the needs of the informed patient. When noninvasive treat-
ment is recommended, physical therapy that is performed by a licensed
physical therapist with an orthopedic specialtydand preferably a subspe-
cialty in TMDsdshould be the rst choice in the treatment of disc displace-
ments without reduction.
Physical therapy procedures may be successful in the treatment of pain
and limited mouth opening that are associated with disc displacement with-
out reduction [3033]. Using various active and passive jaw exercises, as well
as intraoral mobilization techniques, physical therapists may restore func-
tional mandibular dynamics without pain when the disc is displaced. Inam-
mation that results from the disc displacement or that coexists with the disc
displacement may be treated as identied previously. An oral appliance that
is fabricated by a dentist also may facilitate the reduction of inammation,
especially if the patient bruxes. If physical therapy and the use of an oral ap-
pliance have not reduced pain to a satisfactory level or regained functional
movements of the jaw after 4 to 12 weeks, the patient should consult with an
oral surgeon to discuss surgical options.
166 KRAUS
Disc displacement with reduction and chronic disc displacement without

reduction. Patients who experience a disc displacement with reduction or
a chronic disc displacement without reduction may have functional move-
ments of the mandible without pain [17]. The rst goal of physical therapy
consists of educating the patient on the cause of his or her joint noises (ie,
reciprocal click or crepitus), so that he or she is aware of the aggravating
factors of the condition. If the patient has TMJ pain that is due to inam-
mation, the goal of physical therapy is to reduce pain and improve mandib-
ular function through manual therapy and exercise interventions, despite the
disc displacement. An oral appliance that is fabricated by a dentist also may
facilitate the reduction of inammation, especially if the patient bruxes.
A patient who has joint inammation that does not respond to an oral
appliance or 4 to 12 weeks of physical therapy may be referred to an oral
surgeon to discuss surgical options.
A physical therapist may attempt to eliminate or decrease joint noises
that are associated with a disc displacement with reduction. Clinically, the
goal of physical therapy treatment is to have functional mandibular dynam-
ics without pain and without noises, despite the disc being displaced perma-
nently. The following criteria are used for patient selection:
Joint noises are disturbing to the patient
Patient experiences intermittent catching/locking with or without pain
during mouth opening
Patient understands that the treatment may (a) cause joint pain or (b)
cause limited mouth opening, or (c) result in having TMJ surgery
because (a) or (b) could not be resolved.
Patient has consulted with a dentist or oral surgeon previously
Exercises and intraoral manual procedures for treating a reducing disc
are not the same as exercises and intraoral manual procedures for increasing
limited mouth opening that is associated with a nonreducing disc and -
brous adhesions. Progressing a reducing disc to a nonreducing disc involves
the application of exercises and intraoral manual procedures that prevent
the disc from reducing on opening. Preventing the disc from reducing on
opening elongates the posterior attachment. Once sucient elongation of
the posterior attachment occurs, the patient can achieve functional opening
without popping with the disc remaining displaced [9,34,35]. The patient
may go through a short period with limited opening and possible pain. In
the authors experience, 4 to 12 weeks is a sucient time to achieve func-
tional mandibular dynamics without pain and with an absence of joint
noises with the disc displaced permanently.
Fibrous adhesions
Fibrous adhesions may appear in the capsular-ligament tissues and in
the upper joint space of the TMJ [36]. Fibrous adhesions can result from
chronic inammation, blunt trauma, postoperative healing of a capsular
incision, or immobility that occurs with intermaxillary xation or from

limited opening that is associated with a disc displacement without reduc-
tion. The physiologic changes that are associated with brous adhesions
are documented in the literature [3740]. Physical therapy procedures
and modalities for the treatment of brous adhesions are similar, but
not identical, to those that are used for treating a disc displacement with-
out reduction. Treating brous adhesions involves applying an intraoral
mobilization technique that is referred to as lateral glide. A lateral
glide passive intraoral mobilization procedure may be performed at the
same time that the patient opens his or her mouth actively. Clinically,
this passive/active mobilization force targets the restrictions in the lateral
aspect of the capsularligament complex of the TMJ. The clinical deci-
sions that are necessary to determine the duration, intensity, frequency,
and progression of exercise intervention strategies require skill and expe-
rience. The eectiveness of a mobilization technique is related to proper
patient selection, appropriate choice of technique, eective execution of
the procedure, and making adjustments that are based on tissue response
and patient feedback. Inappropriate management of a mechanical dys-
function of the TMJ by untrained personnel may lead to an exacerbation
of symptoms and a worsening of the condition.
Temporomandibular disorders: myogenous

Masticatory muscle pain
Masticatory muscle pain is a common clinical nding in patients who ex-
perience head and orofacial pain [41]. The relationship between bruxism and
masticatory pain is unclear [42]; however, parafunctional activity, such as
bruxism, may be a predisposing, precipitating, or perpetuating factor of
masticatory muscle pain [43,44]. The common treatment for managing brux-
ism/masticatory pain is an oral appliance [1]. Oral appliances have been
shown to be eective in the treatment of masticatory pain [45,46].
Physical therapists may provide treatments that oer symptomatic relief
in masticatory muscle pain through modalities and therapeutic procedures.
Modalities, such as iontophoresis, ultrasound, and electric muscle stimula-
tion, may help to reduce muscle pain [9]. Intraoral and extraoral soft tissue
mobilization to the muscles of mastication also may provide symptomatic
relief [9]. Therapeutic exercises to the mandible that consist of isometric, iso-
tonic, and eccentric contraction have been observed clinically to reduce mas-
ticatory muscle pain [30]. Patient education strategies that are related to oral
modications and enhancing self-awareness about aggravating factors also
have been shown to provide relief in masticatory muscle pain [47]. Oral
modications consist of diet changes as well as eliminating or limiting
oral habits, such as gum chewing and nail, lip, or cheek biting. Self-aware-
ness strategies also include instructing the patient on the proper rest position
of the tongue and mandible. Patients who take an active role in making oral
168 KRAUS
modications and performing neuromuscular exercises may achieve satisfac-

tory daytime relief from masticatory muscle pain. Decreasing the cumulative
loading during the day also may provide relief in nighttime pain that is
associated with bruxism. Nocturnal bruxism is more dicult to treat, even
when the patient wears an oral appliance. Physical therapists can assist in
reducing nocturnal bruxism by addressing head and neck positioning while
sleeping. Instructing the patient on proper selection and usage of pillow sup-
port that is appropriate for their cervical spine alignment and motion func-
tion may help to lessen the tendency for bruxism at night by enabling a more
restful mandibular position. Cervical spine disorders that may contribute to
bruxism are covered in a later section.
Cervical spine considerations in the management of temporomandibular

disorders and head and orofacial pain
The coexistence of neck pain and TMD is common [4861]. One study
found that neck pain is associated with TMD 70% of the time [55]. There
also is a high occurrence of neck pain in patients who have facial pain. A
study was conducted on 200 consecutive female patients who were referred
to a university facial pain clinic. The patients were asked to mark all painful
sites on sketches that showed contours of a human body in the frontal and
rear views [62]. An analysis of the pain distribution according to the
arrangements of dermatomes revealed three distinct clusters of patients:
(1) those with pain restricted to the region innervated by the trigeminal
nerve (n 37); (2) those with pain in the trigeminal dermatomes and any
combination involving the spinal dermatomes C2, C3, and C4, but no other
dermatomes (n 32); and (3) those with pain sites involving dermatomes in
addition to those listed in (1) and (2) (n 131).
In summary, the pain distribution of the 200 patients who had facial pain
is more widespread than commonly assumed [62]. One hundred and sixty-
three of 200 patients had pain that extended outside of the head and face
to areas that included the C2, C3, and C4 dermatomes [62]. Other studies
also have concluded that patients who have head and orofacial pain often
experience widespread pain in the neck and shoulder areas [63,64].
A systematic review of the association between cervical posture and
TMDs has been conducted [65]. The review examined 12 studies that satis-
ed the same inclusion criteria for participants. It concluded that an associ-
ation between TMDs and cervical posture is unclear. The uncertainty of the
association between TMDs and cervical posture was related to poor meth-
odologic quality of the 12 studies [65]. Determining the typical resting pos-
ture of the head and neck for a study that evaluates upper body positional
relationships is dicult, because all individuals assume many dierent head
and neck postures during the course of a days activities. Perhaps future
studies that investigate cervical spine and TMD relationships should
account for the dynamics of the cervical spine, instead of focusing on rest
positions. The relationship of mandibular dynamics and the cervical spine
needs to be analyzed in future studies by using reliable clinical instrumenta-
tion to compare active movements of the cervical spine to mandibular open-
ing and closing or masticatory muscle pain.
The following section highlights cervical spine considerations in the man-
agement of TMD; it is followed by a discussion on cervical spine consider-
ations for head and orofacial pain.
Cervical spine considerations with temporomandibular

disordersarthrogenous involvement
The TMJ is a load-bearing joint [1]. TMJ inammation may be perpetu-
ated by bruxism that loads the joint excessively [66,67]. An oral appliance
helps to control bruxism [24]; however, not all patients respond favorably
to an oral appliance that is designed to control bruxism. Many variables
can contribute to bruxism, which is why an oral appliance may not always
be therapeutic in controlling bruxism. One variable is cervical spine involve-
ment. Decreasing the intensity and duration of bruxism by managing cervi-
cal spine disorders may reduce pain that originates from arthrogenous
involvement. Cervical spine involvement as a cause of masticatory muscle
pain or bruxism is discussed later in this article.
Typically, full mouth opening is accompanied by extension of the head,
whereas mouth closing typically is accompanied by exion of the head [68].
A frequently observed abnormal posture involves an extended headneck
position which is a component of forward head posture. The forward
head posture may facilitate wider mouth opening during functional activi-
ties, such as yawning and eating a large sandwich. Increasing patient
awareness of forward head posture and instruction in correcting forward
head posture during sitting, standing, and walking may control excessive
mouth opening that is associated with hypermobility; it should be a part
of the conservative management program for every patient who has
a TMD.
On the other hand, if the objective is to facilitate mouth opening, physical
therapists may position the patients head and neck in slight extension dur-
ing procedures (eg, intraoral mobilization and staticdynamic jaw exercises)
that increase mouth opening. When the patient stands for mouth-opening
exercises, the patient is instructed to allow his or her head to extend slightly
while opening.
Patients often believe that their head and orofacial pain are due entirely
to their disc displacement. Many patients believe that the only way to feel
better is to have the disc put back into place. This may be true, however,
in only a small percentage of patients who have a disc displacement. Often,
the source of the patients pain is independent of the disc displacement. In-
stead, it originates from TMJ inammation, overactive masticatory muscles,
170 KRAUS
and irritation of the pain-sensitive structures of the cervical spine. Cervical

spine involvement as a source of head and orofacial pain is discussed later.
Cervical spine considerations with temporomandibular

disordersmyogenous involvement
Bruxism is more common in patients who have myofascial pain in the
masticatory and cervical spine muscles [51]. Patients who have TMDs report
neck symptoms more frequently than do patients who do not have TMDs;
patients who have neck pain report more signs and symptoms of TMDs
than do healthy controls [58]. Neck and shoulder pain is more prevalent
in patients who have a TMD with a myogenous component than in patients
who have a TMD with an arthrogenous component [56]. Therefore, the
prevalence of neck pain coexisting with masticatory pain may be more
than a coincidence. Cervical spine involvement as a predisposing, precipitat-
ing, or perpetuating variable to masticatory muscle pain or bruxism is high-
lighted in the following three theories.
Theory one
The rst theory is that aerent input that is associated with neck pain
converges onto trigeminal motor neurons in the trigeminocervical nucleus,
which results in an increase in masticatory muscle hyperactivity and pain.
Motor activity of trigeminal-innervated muscles of mastication increases
when tissues that are innervated by upper cervical spine segments are irri-
tated experimentally [6973]. Little information on human subjects is avail-
able regarding the inuence of experimental pain in the neck and shoulder
muscles on motor activity in the orofacial region. One study was done to
clarify the eects of experimental trapezius muscle pain on pain spread
and on jaw motor function [74]. Experimental pain was induced in the supe-
rior border of the trapezius muscle of 12 subjects, aged 25 to 35 years of age,
by injecting 0.5 mL of hypertonic (6%) saline. Results showed pain spread
over a wide area to include the temporomandibular region, with pain refer-
ral accompanied by a reduction of mouth opening [74]. Aerent nociceptive
input from the neck muscles may excite eerent (motor) neurons of cranial
V, which results in contraction of masticatory muscles [75,76]. Similar con-
vergences and central excitation phenomenadas seen with cervical and tri-
geminal sensory neuronsdalso may exist for trigeminal motor neurons
[77,78].
Theory two
The second theory is that masticatory muscles contract in response to the
contraction of cervical spine muscles. A neurophysiologic interplay exists
that involves a synergistic relationship between the cervical spine and the
muscles of mastication under normal circumstances [7985]. Synergistic
co-contraction can be observed with jaw and neck muscles during activities
involving chew, talk, and yawn. Reciprocal innervations of opposing mus-
cles has been demonstrated [82]. The cervical spine muscles and the muscles
of mastication can be viewed as agonistic and antagonistic to one another
[83]. In overt motor patterns, such as walking, augmentation and diminu-
tion of antagonistic muscles contracting concurrently (co-contraction)
with agonist muscles contracting has been demonstrated [84,85].
Sometimes common daily events may cause the muscles of mastication to
disproportionately contract in response to cervical muscles contracting.
Head, neck, shoulder girdle, and upper extremity posture must be positioned
precisely during eyehand coordination activities, such as writing, painting,
computer work, and driving. A task that involves a specic head and neck
posture requires a constant low-level contraction of the cervical spine mus-
cles. The longer that a subject spends on maintaining a specic headneck
posture, the more likely an exaggerated contraction of the muscles of masti-
cation will occur in response to cervical spine muscles contracting.
Isometric, isotonic, or eccentric contractions of cervical spine muscles oc-
cur during lifting, carrying, pushing, pulling, and reaching activities. When
cervical spine muscles perform repetitive activity, under load, and over
a long duration, the more likely it is that the muscles of mastication will dis-
proportionately contract.
Theory three
The third theory is that the patient bruxes in response to neck pain. Pa-
tients start to brux or the intensity and frequency of their bruxing may be ex-
acerbated by their response to acute or chronic neck pain.
Thus, a neurophysiologic interplay exists between the muscles of mastica-
tion and the cervical spine, which needs to be addressed in the thorough
management of the patient who has a TMD. Although these three theories
need further clinical research, physical therapists observe that treating cervi-
cal spine pain often decreases masticatory muscle pain. Consequently, neck
pain should be added to the list of factors that contribute to bruxism and
masticatory muscle pain.
Cervical spine considerations with oral appliances

Common treatments for masticatory muscle pain are medication and ap-
plication of an oral appliance, both of which can be oered by a dentist or
oral surgeon [24]. Physical therapists should be familiar with the dierent
structural designs of splints as well as be able to explain the rationale and
therapeutic benets for oral appliance use [46,86,87].
One common feature of the use of oral appliances and postural re-
education/manual therapy intervention of cervical spine dysfunction is
that both treatment strategies inuence the rest position of the mandible.
Rest position of the mandible determines the initial path of closure into
172 KRAUS
tooth-to-tooth contact or teeth contact onto an appliance [88]. The design of

an oral appliance inuences the vertical and horizontal positions of the man-
dibular rest position; this changes the path of mandibular closure and aects
how the teeth and oral appliance make contact [89].
Conversely, head and neck posture also inuences the vertical and hori-
zontal positions of the mandibular rest position, which subsequently alters
the path of closure into teeth-to-teeth contact [9098]. Mohl [90] stated,
if the rest position is altered by a change in head position, the habitual
path of closure of the mandible must also be altered by such a change.
Clinically, physical therapists have recognized that cervical spine motion re-
strictions and forward head posture aect mandibular closure, which, in
turn, alters how the teeth and oral appliance make contact.
Patients may complain that they do not hit, bite, or make con-
tact evenly on their appliance. If the patients complaint cannot be ex-
plained by interferences that are caused by the appliance design, the
dentist should consider a mechanical disorder within the cervical spine
that aects the path of closure of the mandible onto the appliance. Pa-
tients who do not to respond to an oral appliance in a 4-week period
may not need more time wearing the appliance or a change in the design
of the appliance [1]. Another alternative is to have a physical therapist
evaluate the cervical spine to assess for possible dysfunctions that might
be interfering with the eectiveness of the oral appliance. Clinically, cervi-
cal spine dysfunction with respect to abnormal posture or motion impair-
ment can be treated before, during, or after the use of an oral appliance.
Favorable outcomes are more likely to be achieved when cervical spine
treatment is rendered concurrently with the use of an oral appliance, ac-
cording to physical therapists who are experienced in managing mastica-
tory muscle pain.
Cervical spine considerations with head and orofacial pain

Symptoms that originate from the cervical spine and require immediate
medical attention secondary to spinal pathology include gross mechanical
instability that may aect spinal cord function, primary bone tumor, meta-
static disease, infections, fracture, and dislocation [99]. Symptoms also may
be referred to the cervical spine from visceral pathology [100]. Red ags
that suggest a visceral pathology should alert the clinician to a nonmusculos-
keletal origin of the patients pain (Box 2). Imaging studies and erythrocyte
sedimentation rates can help in detecting whether an underlying pathology
is present [101].
Most cervical spinerelated symptoms are not caused by spinal or visceral
pathology [102]. Nonpathologic symptoms may originate from disc disor-
ders, nerve root irritation, spinal cord compromise secondary to spinal ste-
nosis, facet joint dysfunction, and myofascial pain. Common medical
diagnoses for each cervical spine tissue are listed in Box 3. Patients
Box 2. Pathologic conditions are suspected with the following

red flags
Fever
Unexplained loss of weight
History of inflammatory arthritis
History of malignancy
Osteoporosis
Vascular insufficiency
Blackouts
History of drug abuse, AIDS, or other infection
Immunosuppression
Lymphadenopathy
Severe trauma
Minor trauma or strenuous lifting in an older patient
Increasing or unremitting pain
Data from Jarvik J, Deyo R. Diagnostic evaluation of low back pain with em-
phasis on imaging. Ann Intern Med 2002;137:58697.
frequently have more than one cervical spinerelated tissue that is the source
of their cervical spinerelated symptoms. Multiple cervical spine tissue in-
volvement can be referred to collectively as cervical spine disorders. Cervical
spine disorders can cause pain or functional limitations of the cervical spine
in which symptoms vary with physical activity or static positioning, which
may develop gradually or follow trauma.
The prevalence of nonpathologic neck pain is high. Seventy percent of the
general population is aected with neck pain at some time in their lives
[103]. Fifty-four percent of the general population has experienced neck
pain in the last 6 months [104]. The general population has a point preva-
lence of neck pain that varies between 9.5% and 22% [105].
Box 3. Common sources of neck symptoms with corresponding

International Classification of Diseases, Ninth Revision (ICD-9)
codes
Disc: 722.6, degeneration; 722.2, herniation
Nerve root: 723.4, cervical radiculopathy
Spinal cord: 721.1, cervical myelopathy
Facet joint: 719.5, hypomobility
Muscle: 728.5, muscle spasm; 729.1, myalgia
174 KRAUS
Head and orofacial pain of cervical spine origin

The International Headache Society has created a list of 144 dierent
headache types that fall into one of 13 categories (Box 4) [106]. The cervical
spine is listed as a possible causative factor for headaches and is reported as
neck in classication 11, subclassication 11.2.
The literature is clear that cervical spine tissues refer pain to the head and
orofacial areas [77,107]. The neuroanatomic mechanism that explains the re-
ferred pain is the convergence between trigeminal aerents and aerents of
the upper three cervical nerves [108]. This convergence occurs in an area
that is referred to as the trigeminocervical nucleus [109]. The trigeminocervi-
cal nucleus is located in the upper cervical spinal cord within the pars cauda-
lis portion of the spinal nucleus of the trigeminal nerve (Fig. 1) [110,111].
Box 4. Classification and diagnostic criteria for headache

disorders, cranial neuralgias, and facial pain
1. Migraine headache
2. Tension-type headache
3. Cluster headache and chronic paroxysmal hemicrania
4. Miscellaneous headache, unassociated with structural lesion
5. Headache associated with head trauma
6. Headache associated with vascular disorders
7. Headache associated with nonvascular intracranial disorders
8. Headache associated with substances or withdrawal
9. Headache associated with noncephalic infection
10. Headache associated with metabolic disorder
11. Headache or facial pain associated with disorder of cranium,
neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial
or cranial structures
11.1 Cranial bones including the mandible
11.2 Neck
11.3 Eyes
11.4 Ears
11.5 Nose and sinuses
11.6 Teeth and related oral structures
11.7 Temporomandibular joint
11.8 Masticatory muscles
12. Cranial neuralgias, nerve trunk pain, and deafferentation pain
13. Headache not classified
Adapted from International Headache Society, Classification Committee. Clas-

sification and diagnostic criteria for headache disorders, cranial neuralgias and fa-
cial pain. Cephalalgia 1998;8(Suppl 7):996.
Primary sources of head and orofacial pain that originate from the cervical
spine lie in the structures that are innervated by C1 to C3 spinal nerves
[111]. The lower segmental levels, C4 thru C7, also may contribute to head
and orofacial pain through the trigeminocervical nucleus [112]. Box 5 lists
the tissues with sensory innervations from the upper three cervical nerves
that contribute to referred symptoms to the head and orofacial areas [111].
The greater occipital nerve (GON) branches o from the C2 nerve root
[113]. GON cutaneous branches and their innervations are:
Medial branch: innervates the occipital skin
Lateral branch: innervates the region above the mastoid process and be-
hind the pinna (the projecting part of the ear lying outside of the head)
Intermediate branches: run rostrally and ventrally across the top of the
skull as far as the coronal suture. Anastomosis of the GON to the
Fig. 1. A sketch of the trigeminocervical nucleus. Aerent bers from the trigeminal nerve
(V) enter the pons and descend in the spinal tract to upper cervical levels, sending collateral
branches into the pars caudalis of the spinal nucleus of the trigeminal nerve and the gray matter
of the C1 to C3 spinal cord segments. Aerent bers from the C1, C2, and C3 spinal nerves
ramify in the spinal gray matter at their segment of entry and at adjacent segments. That col-
umn of gray matter that receives trigeminal and cervical aerents constitutes the trigeminal
nucleus (black). (From Bogduk N. Cervical causes of headache and dizziness. In: Grieve G,
editor. Modern manual therapy. 2nd edition. Edinburgh (UK): Churchill Livingstone; 1986.
p. 317, with permission.)
176 KRAUS
Box 5. Sensory innervations from the upper three cervical

nerves
C1 sensory innervation
Suboccipital tissues and muscles
Atlantoccipital and atlantoaxial facet joints
Paramedian dura of the posterior cranial fossa and dura
adjacent to the condylar canal
Upper prevertebral muscles (longus capitis and cervicis
and the rectus capitis anterior and lateralis)
Skin of the occiput
Upper posterior neck muscles; semispinalis capitis,
longissimus capitis and splenius capitis, the
sternocleidomastoid, trapezius, and prevertebral muscles
Atlantoaxial facet joint
Paramedian dura of the posterior cranial fossa
Lateral walls of the posterior cranial fossa
Multifidus, semispinalis capitis, sternocleidomastoid,
trapezius, and prevertebral muscles
Suboccipital skin
C2/3 facet joint
Cervical portion and intracranial branches of the vertebral
artery
supraorbital nerve, which is a trigeminal branch, occurs at the coronal

suture.
Trauma or suboccipital muscle tightness may involve the GON, referred
to as occipital neuralgia [114]. Symptoms that are associated with occipital
neuralgia refer to the occipital area, top of the skull, TMJ area, and in or
around the ear [115,116].
Cervicogenic headache
The term cervicogenic headache was used rst in 1983 by Sjaastad and
colleagues [117]. Cervicogenic headache refers to head and orofacial pain
that originates from the cervical spine tissues. Cervicogenic headache can
be a perplexing pain disorder [118]. The following is a clinical presentation
of cervicogenic headache as described by Sjaastad et al [117]:
The pain is usually unilateral but when severe can be felt on the opposite
side. It is a head pain and not just a neck pain. The main manifestation
of the headache is in the temporal, frontal, and ocular areas. It has uctu-
ating long-term course with remissions and exacerbations; some patients
have a continuous basal headache, others do not. During the headache at-
tack, there may be the following accompanying phenomena; ipsilateral
blurring and reduced vision, a migrainous phenomena like nausea and
loss of appetite; there may even be vomiting. Phonophobia and photopho-
bia occur frequently. Some patients complain of dizziness and of diculty
swallowing during symptomatic periods. Even between attacks, patients
may feel stiness and reduced mobility of the neck.
Prevalence of cervicogenic headache

Cervicogenic headache is one of the three large headache groups; the
other two are tension-type headache and common migraine without aura
[119]. Cervicogenic headache accounts for 15% to 35% of all chronic and
recurrent headaches [119121].
Although cervicogenic headache has been diagnosed more frequently
over recent years, it also has been misdiagnosed because of the consider-
able overlap in symptoms with more popular causes of headache (ten-
sion-type and migraine) [117,122,123]. Cervical pain and muscle tension
are common symptoms of a migraine [124,125]. In a study of 50 patients
who had migraine, 64% reported neck pain or stiness associated with
their migraine, with 31% experiencing neck symptoms during the pro-
drome, 93% experiencing neck symptoms during the headache phase,
and 31% experiencing neck symptoms during the recovery phase [124].
Other studies show that neck pains often coexist with migraine headaches
[126,127]. In addition, cervical muscles may play a role in the pathogenesis
of migraine headaches [128]. Patients often suer several headache types
concurrently [129]. Patients may require medications for migraine,
application of an oral appliance for tension headache, and physical ther-
apy for cervicogenic headache. In summary, many patients are misdiag-
nosed to have migraine or tension type headaches, when in fact these
patients actually have headaches of cervical origin. Therefore, the appro-
priate treatment should be targeted to mechanical dysfunction or muscle
tension in the cervical spine.
Dizziness
Dizziness and vertigo refer to a false sensation of motion of the body,
which patients describe as a spinning or swaying feeling [130,131]. They
are synonymous terms that are used to describe spinning, swaying, the sub-
jective accompaniments of ataxia, and a variety of other colloquially de-
scribed sensations. Dizziness may result from involvement of the eyes, the
parietal and temporal lobes, and cerebellumdmost commonly as a result
of disease aecting the labyrinth or the vestibular nuclei [132,133]. In the ab-
sence of disease, the vestibular nuclei can be aected by disorders of the
neck in two ways: through ischemic processes or disturbances of neck
178 KRAUS
proprioceptors [133]. Disturbance of the vestibular nuclei secondary to dys-

functional neck proprioceptors are addressed for this discussion.
Aerent input from neck proprioceptors (ie, facet joints and muscles) is
believed to aect the vestibular nuclei activity, which results in a variety
of motor and subjective abnormalities [133]. Cervical facet joints and mus-
cles may produce a generalized ataxia, with symptoms of imbalance, disori-
entation, and motor incoordination [134139]. Vertigo, ataxia, and
nystagmus were induced in animals and man by injecting local anesthetic
into the neck [140]. The injections presumably interrupted the ow of aer-
ent information from joint receptors and neck muscles to the vestibular
nuclei. Vertigo following a whiplash injury (an extension/exion movement
of the head and neck) may be due to aerent excitation that originates from
cervical muscles, ligaments, facet joints, and sensory nerves [141]. Patients
who do not respond to treatments for dizziness that is believed to be origi-
nating from the eye, inner ear, or sinus should be suspected of having cervi-
cogenic vertigo. Patients who experience cervicogenic vertigo may complain
of pain, stiness, and tightness in the neck; they are good candidates for
physical therapy intervention that focuses on the cervical spine [142,143].
Subjective tinnitus and secondary otalgia

Objective tinnitus is characterized by physiologic sounds and represents
only 1% of cases of tinnitus. Subjective tinnitus is an otologic phenomenon
of phantom sounds. Although 10% of the population suers from subjective
tinnitus, its cause is unknown [144].
Subjective tinnitus has been related to cervical spine involvement. The
sensory upper cervical dorsal roots and the sensory components of four cra-
nial nerves (V, VII, IX, X) converge on a region of the brain stem that is
known as the medullary somatosensory nucleus [145]. Subjective tinnitus
is a neural threshold phenomenon and cervical muscle contraction alters
the neural activity that is responsible for tinnitus [146]. One hundred and
fty patients were tested with a series of head and neck maneuvers to assess
whether any of the maneuvers changed their subjective tinnitus. Eighty per-
cent of patients had increased tinnitus during the test [146]. A similar study
tested 120 patients who had subjective tinnitus and 60 subjects who did not
have tinnitus [147]. The ndings showed that forceful head and neck con-
tractions, as well as loud sound exposure, were signicantly more likely to
modulate ongoing auditory perception in people who had tinnitus than in
those who did not have tinnitus [147]. This study supports the concept
that subjective tinnitus has a neural threshold [147].
Secondary otalgia (ie, earache not caused by primary ear pathology) is
common in patients who are suering from earache [148]. In a standardized
examination and interview of 100 subjects, 91 subjects had secondary otalgia
and 9 had primary otalgia [149]. An epidemiologic study investigated sub-
jects who had secondary otalgia during a 2-year follow-up period [150].
Subjects who had secondary otalgia had pain with palpation over the mas-
ticatory muscles and TMJ, and reported neck and shoulder pain more fre-
quently than did the individuals who did not have secondary otalgia [150].
Kuttila and colleagues [149] investigated whether secondary otalgia is asso-
ciated with cervical spine disorder, TMDs, or both [149]. Most of the sub-
jects who reported secondary otalgia also had signs and symptoms of
cervical spine and TMD involvement. An examination of the cervical spine
and TMD is recommended as a routine diagnostic process for patients who
have secondary otalgia.
Cervical spine examination

History
Orthopedic-related cervical spine problems are suspected rst during the
history. Primary symptoms of cervical spine disorders are neck, shoulder,
and upper extremity pain and headaches (cervicogenic). Cervicogenic head-
aches are described by patients as pain that projects from the neck to the
forehead, orbital region, temples, vertex, or ears. The symptoms for cervico-
genic headaches as identied by the International Headache Society criteria
for cervicogenic headache are listed in Box 6 [151]. Symptoms, such as diz-
ziness, ear pain (secondary), and subjective tinnitus, also may have a cervico-
genic origin. A complete list of cervical spinerelated symptoms in shown in
Box 7 [152].
The patients symptoms can be quantied by documenting frequency, in-
tensity (visual analog scale), and duration of symptoms. This information
can be used to monitor the patients response to treatment. The Copenhagen
Neck Functional Disability Scale or the Functional Rating Index can be
used to document improvement [153,154]. Duration of sleeping and sitting
as well as the patients ability to reach, pull, and lift are documented in
a measurable manner. Change in medication intake also can be used to
monitor the patients response to treatment.
Physical examination
A physical examination of the cervical spine involves tests that incrim-
inate nerve involvement. Often, neurologic signs are the result of nerve
root compromise and are referred to as cervical radiculopathy, whereas
spinal cord compromise is referred to as cervical myelopathy. Aside
from physical tests that evaluate nerve function (manual muscle tests, sen-
sory tests, reex responses, and nerve tension tests), the physical therapy
examination assesses for motion impairments of the cervical spine that in-
uence gross range of motion or result in abnormal segmental vertebral
motion that corresponds to the patients symptoms and functional limita-
tions. Palpatory tests evaluate for myofascial pain and dysfunction with re-
spect to tenderness, and tightness. Pain also can be accessed upon
180 KRAUS
Box 6. International Headache Society criteria for cervicogenic

headache
A. Pain localized in the neck and occipital region. May project
to the forehead, orbital region, temples, vertex, or ears.
B. Pain is precipitated or aggravated by special neck movements
or sustained neck posture.
C. At least one of the following occurs:
a. Resistance to or limitation of passive neck movements
b. Changes in neck muscle contour, texture, tone or response
to active and passive stretching and contraction
c. Abnormal tenderness in neck muscles
D. Radiologic examination reveals at least one of the following:
a. Movement abnormalities in flexion/extension
b. Abnormal posture
c. Fractures, congenital abnormalities, bone tumors,
rheumatoid arthritis, or other distinct pathology
(not spondylosis or osteochondrosis)
Adapted from International Headache Society. Classification and diagnostic

criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia
1998;8(Suppl 7):996.
contraction of the muscle. Manual muscle and neuromotor tests are used
to assess strength and coordination. A postural analysis is included to eval-
uate for possible areas of stress concentration. Physical therapists often de-
termine the patients response to manual traction during the initial
examination to evaluate the need for mechanical cervical traction treat-
ment. Physical examination procedures are listed in Box 8. Imaging studies
may be needed if the history and physical examination ndings are ques-
tionable or vague.
Treatment strategies for cervical spine and related symptoms

Invasive procedures
Treatment guidelines, such as the Scientic Monograph of the Quebec
Task Force on Whiplash-Associated Disorders and Evidence-based Practice
Guidelines for Interventional Techniques in the Management of Chronic
Spinal Pain, recommend a noninvasive approach in the treatment of cervical
spine symptoms with or without neurologic signs [152,155]. Only after
unsuccessful conservative treatment should invasive procedures be consid-
ered [156]. Invasive procedures include epidural injections, nerve root
Box 7. Symptoms that may originate from cervical spine

disorders
Neck/shoulder pain
Reduced/painful neck movements
Numbness, tingling or pain in arm or hand
Reduced/painful jaw movement
Headaches
Dizziness/unsteadiness
Nausea/vomiting
Difficulty swallowing
Ringing in the ears
Vision problems
Numbness, tingling, or pain in leg or foot
Lower back pain
Memory problems
Problems concentrating
Data from Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of
the Quebec Task Force on Whiplash-Associated Disorders: redefining whiplash
and its management. Spine 1995;20(8 Suppl):1S73S.
injections, facet joint denervation, myofascial trigger point injections, and

surgery (ie, cervical fusion).
Unless neurologic signs suggest otherwise, patients who have symptoms
of radiculopathy or myelopathy should be considered for surgery after con-
servative care has failed. Three studies examined the eects of surgery and
conservative care on pain for sensory loss and weakness in patients who
had minimal to moderate cervical radiculopathy or myelopathy. Two stud-
ies were prospective, randomized studies that evaluated a total of 130 pa-
tients; the other study was a randomized study that involved 68
participants [157159]. No dierences were found in sensation or motor
strength between the patients who were treated surgically and those who
were managed conservatively in follow-up examinations at 24 and 36
months. Therefore, patients need to be informed that the long-term out-
comes for conservative treatment of minimal to moderate cervical radicul-
opathy or myelopathy may be the same as having surgical intervention,
and in some cases, the only reason for selecting a surgical approach may
be to achieve faster pain relief.
Conservative care
Patients who have neck pain can choose from several complementary/al-
ternative treatments that may be part of a physical therapists knowledge
182 KRAUS
Box 8. Procedures used to diagnose cervical spine disorders

(disc, nerve root, spinal cord, facet joint, and muscle)
Neurologic testing for nerve function
Deep tendon reflex
Sensation
Strength
Spurlings test
Hoffmans reflex
Lhermittes test
Nerve tension tests
Active range of motion
Passive range of motion
Cardinal plane movement
Intersegmental movement
Muscle contraction (isometric/isotonic/eccentric)
Palpation
Muscles
Facet joints
Greater occipital nerve
Manual traction
Posture
and skill base. Complementary and Alternative Medicine (CAM) is a diverse

group of health-related professionals that have not documented the thera-
peutic value of their alternative treatments (eg, magnet therapy, crystal
application) through randomized clinic trials [160]. Physical therapy, how-
ever, is not CAM. Physical therapists oer evidence-based treatments for
TMDs and cervical spine disorders with data that are well documented in
peer-reviewed journals [161167]. Physical therapists follow evidence-based
guidelines using a multimodal conservative treatment approach for cervical
spine symptoms that consists of manual therapy, exercise, patient education,
and mechanical cervical traction.
A multicenter, randomized, controlled trial with unblinded treatment and
blinded outcome measures was conducted to investigate the ecacy of phys-
ical therapy management of cervicogenic headache [168]. A group of 200
participants who met the diagnostic criteria for cervicogenic headache was
randomized into four treatment groups: manipulative therapy, exercise ther-
apy, combined therapy, and no treatment. The primary outcome measured
was a change in headache frequency. Other outcomes evaluated included
changes in headache intensity and duration, improvement in the Northwick

Park Neck Pain Index, reduction in medication intake, and patient satisfac-
tion. The physical outcomes evaluated included pain on neck movement,
upper cervical joint tenderness, a craniocervical exion muscle test, and
a photographic measure of posture. The treatment period was 6 weeks
with follow-up assessment after treatment, then at 3, 6, and 12 months.
At the 12-month follow-up assessment, manipulative therapy and specic
exercise had reduced headache frequency and intensity and neck pain signif-
icantly, and eects were maintained (P ! .05 for all). In summary, manip-
ulative therapy and specic therapeutic exercise reduce the symptoms of
cervicogenic headache in the short and long term [168].
Manual therapy
Manual therapy techniques consist of a continuum of skilled passive
movements to joints or related soft tissues that are applied at varying speeds
and amplitudes, including a small-amplitude/high-velocity therapeutic
movement [169]. Mobilization (nonthrust) or manipulation (thrust), when
used with exercise, is eective for alleviating persistent pain and improving
function when compared with no treatment. When compared with each
other, neither mobilization nor manipulation is superior [161]. The psycho-
logic, neurophysiologic, and mechanical benets of manual therapy have
been covered adequately in the literature [170,171].
Exercise
Exercises may be eective in treating and preventing neck pain [172]. Spe-
cic exercises combined with manual therapy may be eective in the treat-
ment of subacute and chronic neck pain, with or without headache, in the
short and long term [155,173]. Physical therapists can identify muscles of
the cervical, shoulder, and thoracic areas that are tight, weak, and have dif-
culty in regulating tension levels. Physical therapists instruct patients in
exercise programs that consist of stretching, strengthening, conditioning,
and coordination that are specic to the patients needs. Modication of
the exercise program frequently is necessary after re-evaluation of the pa-
tient, and is dependent upon the changes in the patients signs and symp-
toms. A successful home exercise program is a function of proper patient
performance and diligence. The skill of the physical therapist in teaching
correct exercise form, making modications in the exercises based on
patients response, and motivating the patient to perform his or her home
program are critical in obtaining an optimal outcome.
Patient education
Patient education focuses on many elements of patient care, and often in-
volves instructing the patient on proper sitting and sleep postures. Support
and encouragement of patients also is important to help them overcome
fear, anxiety, and misconceptions about their condition. Frequently, well-
184 KRAUS
meaning advice from friends or family members may interfere with recovery
because of misbeliefs or incorrect information. In some cases, incorrect
information is being received from online computer resources that the pa-
tient has read. Frequently, physical therapists must dispel myths that the pa-
tient may have obtained from dierent sources to alleviate anxiety-fear and
manage pain [174,175].
Patients are educated about the meaning of their diagnosis by physical
therapists because physical therapists typically spend more time with the
patient than do medical professionals. Patients often perceive that
something is wrong (ie, irreversible) from a medical diagnosis, such as de-
generative joint disease, when degenerative joint disease in itself is neither
predictive of, nor strongly correlated with, the patients symptoms. In this
way, a medical diagnosis may enhance the feelings of fear and anxiety,
which can intensify symptoms and lead the patient to believe that a cure
is not available [176]. Patients can become preoccupied with their diagnosis
and often seek invasive treatment in an attempt to x the condition.
The health practitioner must understand that a patients fear, misunder-
standing, and beliefs about the meaning of pain may determine whether he
or she progresses from acute to chronic neck pain [177]. A patient is less
likely to develop a chronic pain mentality when he or she is educated
about the condition secondary to the knowledge obtained about the med-
ical diagnosis and symptoms. The physical therapist plays a major role in
reducing patient anxiety and fear by keeping the patient focused to
functional goals.
Mechanical cervical traction

Traction is a treatment that is based on the application of a longitudinal
force to the axis of the spinal column. Medically accepted uses for spinal
traction include soft tissue tightness, joint stiness, cervical radiculopathy,
and cervical myelopathy that are caused by disc degeneration or disc herni-
ation [178]. The therapeutic value of traction was demonstrated in a trial of
30 patients who had unilateral C7 radiculopathy [179]. Patients were
assigned randomly to a control group or an experimental group. The appli-
cation of cervical traction, combined with electrotherapy and exercise, pro-
duced an immediate improvement in the hand-grip function in patients who
had cervical radiculopathy compared with the control group that received
electrotherapy/exercise treatment [179]. Although this is only one study
that provides support for the use of mechanical traction, it does demonstrate
its potential for radicular signs and symptoms.
The benets of neck traction are optimal when performed with the patient
in a supine position. The traction unit should not pull through the mandible,
but only through the base of the skull/mastoid process areas. Guidelines are
available that recommend angle of pull, poundage, and duration of pull
[178]. A physical therapist considers the patients signs and symptoms to ad-
just the force and duration of stretch to get the desired results.
Summary
Physicians, dentists, oral surgeons, and physical therapists need to work
together to achieve the best outcomes for patients who experience TMDs
and head and orofacial pain. Physical therapists play an important role in
the conservative care of TMDs and cervical spine disorders that cause
head and orofacial pain. Physicians and dentists should keep in mind that
not all physical therapists have specialty practices that focus on TMDs
and cervical spine disorders. Therefore, referral to an orthopedic physical
therapist who specializes in TMDs and cervical spine disorders is important
for the appropriate management of the patient.
Physical therapists treat TMDs that are secondary to inammation, hy-
permobility, disc displacements, brous adhesions, and masticatory muscle
pain and bruxism. Studies have shown that masticatory muscle pain and
bruxism may be perpetuated by cervical spine involvement. Research evi-
dence suggests a neurophysiologic interplay between the muscles of mastica-
tion and the cervical spine muscles. The cervical spine should be evaluated
and treated when patients TMD symptoms do not respond to medication
and an oral appliance.
Often, cervical spine involvement is a misdiagnosed or unrecognized
source of head and orofacial pain (ie, headache), dizziness, subjective tinni-
tus, and secondary ear pain. Head and orofacial pain that originates from
the cervical spine is referred to as cervicogenic headache. Cervicogenic head-
ache symptoms can be similar to other common headache disorders, such as
migraine or tension-type headache.
Cervical spine disorders that are treated by physical therapists using ev-
idence-based interventions, such as manipulation/mobilization and thera-
peutic exercise, can decrease the protracted course of costly treatment and
reduce the patients pain. Physical therapists, therefore, have an important
role in the management of head-neck and orofacial pain. Patients who pres-
ent with TMD and cervical spine disorders many times can be eectively
treated by a physical therapist that has specialized skills and experience.
Consequently, physical therapists should be an important member of the
group of health practitioners who work with patients who have head,
neck, and orofacial pain.
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Dent Clin N Am 51 (2007) 195208
Temporomandibular Joint Surgery

for Internal Derangement
M. Franklin Dolwick, DMD, PhD
Division of Oral and Maxillofacial Surgery, University of Florida College of Dentistry,
PO Box 100416, Gainesville, FL 32610-0416, USA
Surgery of the temporomandibular joint (TMJ) plays a small, but impor-

tant, role in the management of patients who have temporomandibular dis-
orders (TMDs). The literature has shown that about 5% of the patients who
undergo treatment for TMDs require surgical intervention [1]. There is
a spectrum of surgical procedures for the treatment of TMDs that ranges
from simple arthrocentesis and lavage to more complex open joint surgical
procedures. Although each surgical procedure has its enthusiastic sup-
porters, the specic criteria for which cases are most appropriate are lack-
ing. Unfortunately, the literature is based more on observation than on
scientically controlled studies. The success of surgery seems to be based
on experience of the surgeon and appropriate case selection. It also is impor-
tant to recognize that surgical treatment rarely is performed alone; gener-
ally, it is supported by nonsurgical treatment before and after surgery. In
other words, surgical success is dependent on a total treatment plan that in-
volves nonsurgical and surgical treatment. Surgery performed alone rarely
has long-term success.
Each surgical procedure should have strict criteria for which cases are
most appropriate. Recognizing that scientically proven criteria are lacking,
this article discusses the criteria for each procedure, ranging from arthrocent-
esis to complex open joint surgery. The discussion includes indications, brief
descriptions of techniques, outcomes, and complications for each procedure.
Temporomandibular joint arthrocentesis

TMJ arthrocentesis is the simplest and least invasive procedure that is
performed in the TMJ [2]. Technically, arthrocentesis is not a surgical
196 DOLWICK
procedure; however, because it usually is discussed with surgical procedures,

it is included in this article. Arthrocentesis consists of TMJ lavage, place-
ment of medications into the joint, and examination under anesthesia. It
usually is performed as an oce-based procedure under local anesthesia as-
sisted with conscious intravenous sedation, although it can be performed
with local anesthesia alone (Fig. 1).
The technique involves the insertion of two 18-gauge needles into the su-
perior joint space of the TMJ under local anesthesia. Through one needle,
100 to 300 mL of Ringers lactate solution is injected into the superior joint
space; the second needle acts as an outow portal, which allows lavage of
the joint cavity. Lysis of adhesions is achieved by intermittent distention
of the joint space by momentarily blocking the outow needle and injecting
under pressure during the lavage. Steroids or sodium hyaluronate may be
injected at the end of the lavage to alleviate intracapsular inammation. Im-
mediately upon completion of the lavage, the needles are removed and the
TMJ is examined to determine freedom of movement. After recovery
from the sedation, the patient is discharged. The patient is placed on a non-
chew soft diet for a few days. Range of motion exercises are started imme-
diately and continued for several days. Analgesics are prescribed as
necessary for pain control.
Multiple studies have reported 70% to 90% success rates for arthrocent-
esis for the management of patients who have painful limited mouth open-
ing [37]. Arthrocentesis does seem to reduce pain and improve opening in
most patients. Although its primary indication is for painful limited mouth
opening, it also may be useful for other conditions that involve
Fig. 1. Arthrocentesis: placement of medication into upper TM joint space after lavage.
TMJ SURGERY FOR INTERNAL DERANGEMENT 197
inammation in the joint. The benet of injecting medications into the joint
is unclear, and yet to be proven. There have been no signicant complica-
tions reported with arthrocentesis. Patients may experience temporary swell-
ing and soreness over the joint area and a slight posterior open bite
malocclusion for 12 to 24 hours after the procedure.
Arthrocentesis has become popular and may be the most common proce-
dure that is performed in the TMJ. The advantages of arthrocentesis are
that it is a simple, cost-eective, minimally invasive procedure with little
morbidity that can be performed in the oce.
Indications for temporomandibular joint surgery

Indications for surgery of the TMJ may be divided into relative and ab-
solute [8]. Absolute indications are reserved for those in which surgery has
an undisputed role, such as tumors, growth anomalies, and ankylosis of the
TMJ.
Because there are no objective criteria for performing TMJ surgery for
the more common pain and dysfunction disorders, the decision to perform
surgery should be made only after thorough evaluation of the patient. Pa-
tient selection seems to be the best determinant of surgical success. The gen-
eral indications for TMJ surgery for the most common disorderdinternal
derangement and osteoarthrosisdare signicant TMJ pain and dysfunction
that are refractory to nonsurgical treatment and there is imaging evidence of
disease.
Although the indications for surgery may seem to be clear, they are not
specic. The rst criterion, signicant TMJ pain and dysfunction, may be
the most important. What distinguishes the surgical candidate from patients
who are not surgical candidates is localization of the pain and dysfunction
to the TMJ. The more localized the pain and dysfunction to the TMJ, the
better is the prognosis for a successful surgical outcome. Conversely, the
more diuse the pain and dysfunction, the less likely it is that surgical inter-
vention will be successful. Surgical candidates should have localized contin-
uous TMJ pain that is moderate to severe and becomes worse during jaw
functions, such as chewing or talking. The pain usually is at its lowest inten-
sity in the morning and worsens as the day progresses. Dysfunction may in-
clude painful clicking, crepitus, or locking of the TMJ. Usually, but not
always, limited mouth opening is preceded by a period of painful clicking
and intermittent locking.
The second criterion, refractory to nonsurgical treatment, also is nonspe-
cic. Although nonsurgical treatment is not specied, most clinicians under-
stand what it implies. Nonsurgical therapy should include some
combination of patient education, medications, physical therapy, an occlu-
sal appliance, and possibly, counseling. Most patients respond successfully
to this treatment; therefore, surgical consideration is reserved only for
198 DOLWICK
patients who fail to respond successfully. The problem is that not all patients
who fail nonsurgical treatment are surgical candidates. Surgical treatment is
limited to those who have pain and dysfunction that arises from within the
TMJ. Patients who have pain and dysfunction that arise from the mastica-
tory muscles or other non-TMJ sources are not surgical candidates and they
will be made worse by surgical intervention.
The third criterion, imaging evidence of disease, seems to be the most ob-
jective; however, imaging ndings should not be interpreted in isolation. The
correlation of imaging ndings of disk derangement and osteoarthrosis with
pain are poor [9,10]. Therefore, imaging evidence should be used to conrm
and support the clinical ndings. The decision for surgical intervention
should be made based on the clinical ndings in conjunction with the impact
of the pain and dysfunction on the well-being of the patient and the prog-
nosis if no treatment is provided.
Surgical interventions include arthroscopy, condylotomy, and open joint
procedures, such as disk repositioning and diskectomy. Randomized clinical
trials that compare these procedures do not exist, so the surgical procedure
selected is based mostly on the surgeons experience. Each procedure does
have specic benets as well as risks. Therefore, the procedure that has
the highest potential for success with the lowest risks and most cost-
eectiveness should be chosen for the patients specic problem. Based on
the authors experience, TMJ arthrocentesis and arthroscopy should be
used for painful, limited opening; condylotomy should be used for TMJ
pain with little or no restriction of opening; and open TMJ surgery should
be reserved for advanced cases of TMJ internal derangement and
osteoarthrosis.
Temporomandibular joint arthroscopy

TMJ arthroscopy is a minimally invasive procedure that generally is per-
formed under general anesthesia in the operating room. It is an equipment-
dependent procedure that requires considerable manual dexterity on the
part of the surgeon. TMJ arthroscopy plays a major role in the surgical
management of TMJ internal derangement and osteoarthrosis.
TMJ arthroscopy involves the placement of an arthroscopic telescope
(1.82.6 mm in diameter) into the upper joint space (UJS) of the TMJ. A
camera is attached to the arthroscope to project the image onto a television
monitor. The surgeon must conceptualize a three-dimensional space on
a two-dimensional image. A second access instrument is placed approxi-
mately 10 to 15 mm in front of the arthroscope. The purposes of this instru-
ment are to provide an outow portal for irrigation and access for
instrumentation of the joint space. The UJS is examined systematically
starting from the posterior aspect and continuing to the anterior aspect.
The examination is started posteriorly by identifying the posterior
attachment tissue. The synovial lining is inspected for the presence of in-
ammation, such as increased capillary hyperemia. The junction of the pos-
terior band of the disk and posterior attachment tissues can be identied
(Fig. 2). Movement of the joint allows for the identication of clicking or
restriction in movement of the disk. As the arthroscope is moved through
the UJS, the articular cartilage is inspected for the presence of degenerative
changes (eg, softness, brillation, tears). The joint space also is inspected for
the presence of adhesions, loose bodies, or other pathology. The integrity of
the disk also is determined as the arthroscope is moved throughout the UJS.
Perforations of the disk or posterior attachment tissues can be identied. Al-
though the lower joint space (LJS) usually is not examined, the presence of
a perforation in the disk or posterior attachment may allow limited exami-
nation of the LJS and condyle. Although sophisticated operative techniques,
which range from ablation of adhesions with lasers to plication of the disk,
have been developed, most surgeons limit the use of arthroscopy to lysis of
adhesions and lavage of the UJS. Lysis of adhesions is accomplished most
often by sweeping the arthroscope or the irrigation cannula through the ad-
hesion and breaking it. After completion of the examination, the joint space
is irrigated thoroughly to remove debris and small blood clots. Usually, the
patient is discharged the same day after recovering from the anesthesia. The
patient is placed on a nonchew soft diet for a few days. Range of motion
exercises are started immediately and continued for several days. Analgesics
are prescribed as necessary for pain control.
Multiple studies report an 80% to 90% success rate with arthroscopic
lysis and lavage for the management of patients who have painful limited
mouth opening [1116]. Most patients have decreased pain and improved
mouth opening. Murakami and colleagues [17,18] showed in studies with
5- and 10-year follow-up that arthroscopic lysis and lavage are successful
for all stages of internal derangement, and that results are comparable to
those obtained with open surgery procedures. Data from surgical
Fig. 2. Placement of arthroscope at the fossa point with view of inamed posterior attachment
and medial capsule.
200 DOLWICK
arthroscopic techniques, such as disk repositioning, are dicult to interpret,

and it is unclear that the outcomes are better than those obtained with sim-
ple lysis and lavage [19,20].
The advantages of TMJ arthroscopy are that it is minimally invasive and
causes less surgical trauma to the joint. Surgical complications are rare and
mostly are limited to reversible eects. Patient recovery is rapid and healing
time is shorter than with open surgical procedures. The disadvantages
include the surgical limitations and the necessity for sophisticated
equipment.
Modied condylotomy
The modied TMJ condylotomy is the only TMJ surgical procedure that
does not invade the joint structures. It is a modication of the transoral ver-
tical ramus osteotomy that is used in orthognathic surgery. Although some
investigators recommend modied condylotomy as the surgical treatment of
choice for all stages of TMJ internal derangement, it seems to be most suc-
cessful when used to treat painful TMJ internal derangement without re-
duced mouth opening [21]. The objective of the procedure is to surgically
reposition the condyle anteriorly and inferiorly beneath the displaced disk
eectively by increasing the joint space between the condyle and the fossa.
The modied condylotomy is performed under general anesthesia usually
as an outpatient procedure; however, it may require an overnight stay in the
hospital. An incision is made intraorally along the anterior border of the
mandibular ramus. After exposure of the lateral aspect of the mandibular
ramus, a vertical cut is made posteriorly to the lingula from the sigmoid
notch to the mandibular angle. After mobilization of the condylar segment
the medial pterygoid muscle is stripped from the segment. The mandible is
immobilized using maxillomandibular xation (MMF). Although the sur-
gery is simple, there is a period of postoperative rehabilitation that involves
2 to 3 weeks of MMF followed by training elastics so that the occlusion is
maintained (Fig. 3).
Hall and colleagues [21] reported a study on 400 patients over a 9-year
period that found good pain relief in about 90% of the patients who were
treated with modied condylotomies. In follow-up studies, Hall and col-
leagues [22] reported a 94% success rate in patients with disk displacement
with reduction; 72% of these patients had a normal disk position when eval-
uated with follow-up MRIs. There was only a 4% complication rate, which
consisted primarily of minor occlusal discrepancies. In a group of patients
with disk displacement without reduction, the success rate for modied con-
dylotomy was slightly less (88%) [23]. The most signicant potential compli-
cation of the modied condylotomy is excessive condylar sag that results in
malocclusion. Despite the simplicity of the procedure and its high success
rate, it has not become widely used. The reasons for this are unclear,
Fig. 3. Modied condylotomy with vertical ramus osteotomy from sigmoid notch to mandib-
ular angle.
but most likely are related to the necessity for MMF and the fear of exces-
sive condylar sag that results in an unstable condylar position with
malocclusion.
Open joint surgery (arthrotomy)

Although the use of open joint surgery has decreased signicantly, it still
has a small, but important, role in the surgical management of TMJ internal
derangement. Although other surgical procedures provide a limited range of
options, open TMJ surgery provides the surgeon with an unlimited scope of
procedures that range from simple debridement of the joint to the removal
of the disk. Disk repositioning procedures are performed less commonly to-
day compared with the 1980s and 1990s, because most patients who have
disks that can be preserved are treated successfully with simpler procedures.
Advanced cases of internal derangement that have degenerative disks and
severe arthritic changes may require diskectomy. Arthroplasty in the form
of bone contouring of the articular eminence or condyle is sometimes neces-
sary, particularly with disk repositioning procedures.
Open joint surgery is indicated for patients who have TMJ internal de-
rangement and osteoarthrosis that failed to respond to simpler surgical pro-
cedures or failed previous open surgery. In the cases of previous surgery, the
surgeon must be hesitant to perform repeated surgery because the success
rate for repeated surgery is low; in fact after two surgeries, it may approach
zero. The surgeon must be certain that the source of the pain or dysfunction
is within the joint. Severe mechanical interference, such as loud, hard clicking
or intermittent locking associated with loud, hard clicking, is an indication to
perform open surgery without performing simpler procedures; experience in-
dicates that simpler procedures are rarely successful in these cases.
202 DOLWICK
Open joint surgery is performed under general anesthesia in the hospital,

and usually requires a 1- to 2-day stay. The most common surgical approach
is by way of a preauricular incision made in front of the ear. An incision that
incorporates the tragus of the ear is used often because it is more cosmetic.
Exposure of the capsule is performed carefully to protect the temporal
branches of the facial nerve. After exposure of the capsule, the UJS is en-
tered. After entering the UJS it is inspected for the presence of adhesions.
The contour and integrity of the fossa and eminence are evaluated, and
lastly the disk is visualized. Evaluation of the disk includes its color, posi-
tion, mobility, shape, and integrity.
Disk repositioning
If the disk is intact and can be repositioned without tension, disk reposi-
tioning can be performed by removing excess tissue from the posterior at-
tachment tissues, repositioning the disk, and stabilizing it with sutures.
Bone recontouring of the glenoid fossa or articular eminence generally is
performed, especially in cases of gross mechanical interference or advanced
degenerative joint disease. The goal of disk repositioning surgery is the elim-
ination of mechanical interferences to smooth joint function. After comple-
tion of the intra-articular procedures, the UJS is irrigated and the soft
tissues are closed.
Immediately after the surgery the patient may experience swelling in
front of the ear and a slight change in occlusion and limited mouth opening
that usually resolve in about 2 weeks. All patients experience some numb-
ness in front of the ear that resolves in about 6 weeks. Patients normally
have moderate discomfort that lasts 1 to 2 weeks. Exercises to improve
range of motion are started immediately after the surgery. Continuation
of postoperative conservative treatments is important to assure a successful
outcome. A soft nonchew diet is recommended for 6 weeks after the
surgery.
The literature indicates that disk repositioning surgery is successful
in 80% to 95% of cases; however, experience indicates that this success
rate may be overstated [2430]. It has been found that although disk repo-
sitioning surgery signicantly reduced pain and dysfunction in 51 subjects
who were evaluated up to 6 years postoperatively, improvement in disk po-
sition was not maintained over the follow-up period for most patients [31].
Despite these ndings, the preservation of a healthy, freely mobile disk is
justied.
Facial nerve injury is the most signicant complication that is associated
with open surgery. Although total facial nerve paralysis is possible, it is rare.
Inability to raise the eyebrow is the most commonly observed nding. This
occurs in about 5% of cases and usually resolves within 3 months. It is per-
manent in less than 1% of cases. Other complications are limited opening
and minor occlusal changes.
Diskectomy
A diseased or deformed disk that interferes with smooth function of the
joint and cannot be repositioned should be removed. Only that portion of
the disk that is diseased and deformed needs to be removed. The synovial tis-
sues should be preserved as much as possible. Only minimal bone recontour-
ing should be performed after removal of the disk, because exposure of bone
marrow may result in heterotopic bone formation. To minimize the risk for
heterotopic bone formation, the placement of an interpositional fat graft into
the joint space is recommended. After completion of the intra-articular pro-
cedures, the joint space is irrigated and the soft tissues are closed (Fig. 4).
The postoperative ndings are the same after diskectomy as described for
disk repositioning. The postoperative recommendations also are the same,
except that a soft, nonchew diet is recommended for 6 months.
Diskectomy of the TMJ has the longest follow-up studies of any proce-
dure for management of TMJ internal derangement. Four studies with at
least 30 years of follow-up report excellent reduction in pain and improve-
ment in function in most patients [3235]. Postoperative imaging studies of
patients who underwent diskectomy generally show signicant changes in
condylar morphology [33]. These changes are believed to be adaptive
changes, not degenerative changes. Despite the excellent long-term success
that is associated with TMJ diskectomy, surgeons seem to be reluctant to
perform this procedure.
The complications that are associated with diskectomy are similar to
those that are associated with disk repositioning. The growth of heterotopic
bone is more common after diskectomy than after other TMJ surgical pro-
cedures. This can be a signicant complication that can result in complete
ankylosis of the joint. The frequency of occurrence of heterotopic bone for-
mation is unclear.
Fig. 4. (A) Exposed upper TMJ space showing lateral tubercle of articular eminence and dis-
placed articular disc. (B) Exposed upper TMJ space showing recontoured articular eminence
and a surgically repositioned articular disc.
204 DOLWICK
Temporomandibular joint replacement

A complete discussion of total TMJ replacement is beyond the scope of
this article. Therefore, the discussion is limited to alloplastic total joint re-
placement in adult patients who have advanced degenerative joint disease,
ankylosis, or complications of previously preformed open surgery. The
use of alloplastic materials to reconstruct or replace the diseased tissues of
the TMJ caused disastrous results in the 1980s and 1990s. The use of
Proplast-Teon and silastic implants caused signicant foreign body reac-
tions with severe destruction of the TMJ structures [3639]. This experience
has led some surgeons to reject the use of alloplastic TMJ prostheses in fa-
vor of autologous tissues, such as costochondral grafts for TMJ reconstruc-
tion [40]. Although there are advantages to using autologous tissues,
recently developed alloplastic TMJ prostheses provide safe and predictably
successful reconstruction of the TMJ (Fig. 5) [41,42].
The use of TMJ Concepts (TMJ Concepts, Ventura, California) Patient-
Fitted Prosthesis and the W. Lorenz TMJ implant (Walter Lorenz Surgical
Inc., Jacksonville, Florida) Stock Prosthesis are discussed. The TMJ Con-
cepts Patient-Fitted Prosthesis is a custom-made implant that has been
used for more than 10 years [41]. The prosthesis consists of a glenoid fossa
implant that has an articular surface made of high molecular weight poly-
ethylene that is attached to a pure titanium mesh. The body of the condylar
prosthesis is made of medical-grade titanium alloy with a cobalt chromium
molybdenum condylar head. The process for making the prosthesis
requires that a head CT be obtained, from which an acrylic model of the
patients skull is made. The planned surgery is performed on the model.
The prosthesis is designed on the model and is sent to the surgeon for
approval. After approval, the patients prosthesis is made using computer
aided design/computer aided manufacturing (CAD CAM) technology.
The Lorenz TMJ Prosthesis is a stock prosthesis. The prosthesis consists
of a glenoid fossa implant that is made of high molecular weight
Fig. 5. TMJ Concepts patient-tted TMJ prosthesis.

polyethylene and a condylar component that is made of cobalt chromium

molybdenum alloy. There are three sizes of implants. The fossa implants
come in small, medium, and large. The articular surface is the same on all
three implants; only the ange varies in size. The condyles come in three
lengths: 45 mm, 50 mm, and 55 mm.
The surgical placement is essentially the same for both implants. The sur-
gery requires preauricular and retromandibular incisions for access to the
TMJ and mandibular ramus. A gap arthroplasty is performed by removing
the diseased condyle or ankylosed bone. Generally, a coronoidectomy also is
performed. After the teeth are placed into MMF, the implants are tted in
the patient and secured using titanium screws. The Lorenz implants are
more dicult to place than are the patient-tted implants, because the
bony structures must be reshaped to t the implants. The MMF is released,
the occlusion is veried, and the range of motion is determined. If these are
acceptable, the wounds are irrigated, a fat graft is placed around the con-
dyle, and the soft tissues are closed.
The surgical outcomes for both prostheses have been excellent. The crite-
ria that are used to determine success in complex patients who have chronic
TMJ pain are relative, and, as such, precise success rates are dicult to de-
termine. Successful outcome generally means that the patient has reduced
pain levels, increased range of motion, improved function, and an absence
of surgical complications. Using these criteria, the success rates are high
for both prostheses. Patients who have had multiple TMJ surgical proce-
dures and who suer from chronic pain generally experience about a 50%
pain reduction and gain 10 to 15 mm of mandibular opening. It should be
emphasized that total TMJ replacement is not necessarily a solution to
the management of chronic pain. The TMJ prosthesis can be used to pre-
dictably restore occlusion and increase range of motion, but pain relief is
variable. Conversely, both TMJ prostheses predictably provide pain-free
restoration of occlusion and range of motion for patients who have TMJ
reconstruction for ankylosis, tumors, or other conditions in which pain is
not a component.
The most signicant complication following TMJ reconstruction with al-
loplastic implants is facial nerve injury. Although uncommon, it does occur
more frequently than following routine open joint surgical procedures, espe-
cially in patients who have had multiple TMJ surgeries. The formation of
heterotopic bone is a common complication that occurs in as many as
20% of cases. Other complications, such as infection, foreign body and
allergic reactions, malocclusion, and implant failure, can occur but are
rare. Complications that require implant removal are unusual.
Unquestionably, TMJ Concepts Patient-Fitted Prosthesis provides the
best TMJ reconstruction. The surgery is easier to perform and the implants
t more accurately than do the Lorenz stock prostheses; however, there is
a need for both types of implants. Patient-tted implants require 1 to 3
months to manufacture, so immediate TMJ reconstruction is not possible.
206 DOLWICK
They also are more expensive than are stock prostheses. There also are sev-
eral situations in which two surgeries are necessary to use patient-tted pros-
thesis. These are (1) patients who have large malocclusions that require
signicant reposition of the mandible to correct; (2) patients who have
extensive bony ankylosis that requires large amounts of bone removal;
(3) combinations of 2 and 3; and (4) patients who have foreign bodies,
such as a previously placed alloplastic TMJ prosthesis, that must be re-
moved before an accurate CT can be obtained. When two surgeries are re-
quired it can be problematic to maintain the occlusion and function after the
rst surgery during the time that the prosthesis is being made. Additionally,
two surgeries are inconvenient for the patient; they cause longer healing
times, expose the patient to greater risks for complications, and are more ex-
pensive. Stock joints can provide adequate reconstruction with a single op-
eration in these situations. Conversely, there are situations in which a stock
prosthesis cannot be used. These occur in patients who have extensive bone
loss at the lateral aspect of the fossa and articular eminence or the mandib-
ular ramus that result in inadequate bone for placement of a stock prosthe-
sis. There is great exibility in the design of patient-tted prostheses, which
allows them to be adapted to a variety of complex clinical situations.
In conclusion, patient-tted and stock TMJ prostheses are available that
provide safe and predictably successful reconstruction of the TMJ in adult
patients. Both types of prostheses are necessary to meet the needs of the
variety of TMJ conditions that require TMJ replacement.
Summary
TMJ surgery has a small, but important, role in the treatment of patients
who have TMJ pain and dysfunction conditions. Patient selection is the
most important consideration in determining a successful outcome. The
most important diagnostic nding is that the pain and dysfunction arises
from within the TMJ. The more localized the pain and dysfunction is to
the joint, the better is the prognosis for surgical intervention. Conversely,
the more diuse the signs and symptoms, the less successful is the surgery.
When surgery is unsuccessful, it usually is because of a failure to recognize
and manage factors, such as parafunction.
Several surgical procedures have been shown to be successful. The sim-
plest procedure that has the best prognosis with the least morbidity should
be selected for each patients specic problem. Unfortunately, there have not
been any randomized controlled studies on surgery; therefore, the decision
to operate and the choice of procedure are based on clinical experience.
Several alloplastic total joint prostheses are approved by the US Food
and Drug Administration and have been shown to be safe and successful.
These devices have greatly improved the management of complicated cases
that involve TMJ degeneration, ankylosis, and tumors.
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Dent Clin N Am 51 (2007) 209224
Neuropathic Orofacial Pain:

Proposed Mechanisms, Diagnosis,
and Treatment Considerations
Christopher J. Spencer, DDS,
Henry A. Gremillion, DDS*
Department of Orthodontics, Parker E. Mahan Facial Pain Center, University of Florida
College of Dentistry, P.O. Box 100437, Gainesville, FL 32610-0437, USA
Todays health care professional is faced with the stark reality that the
most common reason patients seek medical or dental care in the United
States is due to pain or dysfunction. Recent studies reveal that the head
and neck region is the most common site of the human body to be involved
in a chronic pain condition [1]. The orofacial region is plagued by a number
of acute, chronic, and recurrent painful maladies. A population-based sur-
vey of 45,711 households revealed that 22% of the United States population
experienced orofacial pain on more than one occasion in a 6-month period
[2]. Pain involving the teeth and the periodontium is the most common pre-
senting concern in dental practice. Non-odontogenic pain conditions also
occur frequently. Recent scientic investigation has provided an explosion
of knowledge regarding pain mechanisms and pathways and an enhanced
understanding of the complexities of the many ramications of the total
pain experience. Therefore, it is mandatory for the dental professional to de-
velop the necessary clinical and scientic expertise on which he/she may base
diagnostic and management approaches. Optimum management can be
achieved only by determining an accurate and complete diagnosis and iden-
tifying all of the factors associated with the underlying pathosis on a case-
specic basis. A thorough understanding of the epidemiologic and etiologic
aspects of dental, musculoskeletal, neurovascular, and neuropathic orofacial
pain conditions is essential to the practice of evidence-based dentistry/
medicine.
E-mail address: [email protected] (H.A. Gremillion).
210 SPENCER & GREMILLION
Pain has been characterized as nociceptive, neuropathic, and mixed.

Nociceptive pain is dened as pain transmitted by normal physiologic
pathways via peripheral nerves to the central nervous system in response
to potentially tissue-damaging stimuli [3]. Examples include frank dental
pain, myofascial pain, and degenerative joint disease. It is typically de-
scribed as diuse aching, stiness, or tenderness. Neuropathic pain refers
to pain initiated or caused by a primary lesion or dysfunction in the ner-
vous system [3]. Conditions representative of neuropathic pain are posther-
petic neuralgia, trigeminal neuralgia, trauma-induced neuropathy, atypical
odontalgia /non-odontogenic toothache, idiopathic oral burning, and com-
plex regional pain syndrome. Neuropathic pain conditions are frequently
associated with qualities with which the patient is not familiar. This may
make it dicult for the patient to communicate their pain experience. Typ-
ical descriptors used by patients include stabbing, burning, electric-like, or
sharp, with numbness or tingling projected to a cutaneous area [4,5]. Ach-
ing pain does not preclude the possibility of a neuropathic basis for the
patients pain [6]. Mixed pain is caused by a combination of primary in-
jury or secondary eects. It is described by a myriad of terms that may
be diagnostically confusing to the practitioner. Each of these types of
pain is associated with variable mechanisms that must be targeted to
optimize treatment outcomes.
Neuropathic orofacial pain

Neuropathic orofacial pain is relatively common. It is diagnosed in
approximately 25 to 30% of patients presenting in a tertiary care
University-based Facial Pain Center (H.A. Gremillion, unpublished data,
2006). It is associated with signicant interpatient variability regarding pre-
sentation and response to treatment. Current scientic evidence supports
a complex pathophysiology.
Chronic neuropathic pain may result from nerve injury or damage. In the
vast majority of cases, chronic neuropathic pain cannot be satisfactorily
treated with conventional analgesics and is generally resistant to opioids
[7]. It is characterized by spontaneous pain that is often unprovoked. Box 1
lists relevant clinical features that are associated with neuropathic orofacial
pain.
Pathophysiology
The pathophysiology of neuropathic orofacial pain has not been fully
elucidated, but a number of mechanisms have been suggested. Change in ex-
citability of primary nociceptive aerents may be the single most important
factor in generation and maintenance of acute chemogenic pain or chronic
neuropathic pain in humans [8].
NEUROPATHIC OROFACIAL PAIN 211
Box 1. Clinical features associated with neuropathic orofacial

pain
Precipitating factors, such as trauma or disease, can typically
be identified.
There may be a delay in onset after initial injury/insult
(days to months).
Typical patient complaints of pain may include burning,
paroxysmal lancinating, or sharp episodes.
Additional complaints may be related to paresthesia or
dysesthesia. Paresthesia is expressed as abnormal, not
necessarily unpleasant, sensations such as heaviness, tingling,
or numbness. Dysesthesia is regarded as abnormal or
unpleasant sensations such as burning, stinging, or stabbing.
The area in which pain is experienced may exhibit sensory
deficit.
Physical examination may reveal allodynia, hyperalgesia,
or sympathetic hyperfunction. Allodynia is defined as pain
resulting from a stimulus that does not normally cause pain.
Hyperalgesia is an increased or exaggerated response to
painful stimuli.
Local pathophysiology is associated with an abnormal nerve
healing (eg, sprouting, neuroma formation).
Deaerentation is dened as a continuous pain after complete or partial

damage to a nerve. It may occur after facial trauma, dental extraction,
placement of dental implants, endodontic therapy (surgical and nonsurgi-
cal), crown preparation, periodontal therapy, and bleaching of teeth. It
may develop after the most perfect procedure if there is a predisposition
or if peripheral or central neural sensitization occurs.
Deaerentation pain is associated with the following clinical characteris-
tics: pain in the structure before amputation, persistent pain after the injured
tissue has healed, discrete trigger areas in the aected region, and pain that
is refractory to usually eective treatments. The estimated incidence of deaf-
ferentation pain postendodontic treatment has been reported to be 3 to 6%
[9,10]. Pulpal extirpation is followed by a degenerative process of primary
trigeminal axons and neurons in the spinal trigeminal nucleus, specically
in subnucleus caudalis. This nding suggests that a central mechanism plays
a role in the ongoing pain condition [11,12].
Demyelination is a degenerative process that is associated with a loss of
integrity of the myelin sheath that normally protects nerve bers. This may
result in an aberration in nerve impulse generation and conduction. Demy-
elination can occur peripherally or centrally. Multiple sclerosis is the most
well known example of a central demyelinating disease. When the disease

aects the trigeminal ganglion, it can present as trigeminal neuralgia. The
peripheral nervous system neurons can undergo pathologic damage from
numerous sources, such as vascular compression, radiation, inammation,
trauma, infection, and exposure to neurotoxins [13]. This damage occurs
in two primary ways: demyelination and axotomy (deaerentation with sev-
erance of the axon). It has long been known that these two phenomena can
produce numbness and paresthesia. More recently it has been shown that
these pathologic entities can cause ectopic discharge or impulse generation
from the sites along the axon where the damage has occurred, rather than
just at the sensory nerve ending [13]. Demyelination can have a disastrous
impact on the individuals quality of life because spontaneous nociceptive
impulses can create severe and unpredictable pain. These same impulses
can cause central sensitization, which can lead to a peripheral allodynia
and hyperalgesia.
New information reveals that the root of this peripheral problem is not at
the synaptic cleft between neurons but rather occurs as a result of membrane
hyperexcitability along the axon [13]. Under normal conditions, the sensory
nerve endings, and an adjacent region of the axon, bring about the transduc-
tion of a stimulus (electrogenesis) to initiate a train of electrical impulses (re-
petitive ring of the neuron) that are propagated and carried by the axon.
Beyond the initial receptors, axons normally have few regions where repet-
itive ring can originate, with the exception of the nodes of Ranvier [14].
Single impulses (a quick sharp electrical feeling) can originate anywhere,
such as can occur with a needle trauma to the lingual or inferior alveolar
nerve during a local anesthetic injection.
With demyelination or axotomy, areas of involvement along an axon can
become ectopic sites of repetitive ring that occur spontaneously or second-
ary to a stimulus. This process involves an abnormal pacemaking ability
whereby the neuronal membrane demonstrates a depolarizing resonance (a
uctuating depolarizing cycle) just below the ring threshold. When com-
bined with a depolarization after potential, it exceeds the threshold and
causes repetitive ring [15]. This pacemaking ability can also create sponta-
neous activity in adjacent uninjured neurons including C-bers (small-
diameter, unmyelinated nociceptive bers) [16]. C-ber damage is generally
associated with burning neuropathic pain.
Studies have recently demonstrated that membrane remodeling, particu-
larly involving Na channels, is responsible for the ectopic repetitive ring
[17,18]. There are three primary ways in which sodium channels aect
a change in membrane hyperexcitability and repetitive ring in damaged
axons. First, there is a change in the rate of protein synthesis of various
Na channels as a result of neuronal injury. More Na channels mean
more sensitivity. For example, Nav1.3 channels have been found to poten-
tially inuence the pacemaking activity previously mentioned. The elevated
rate of synthesis of these proteins occurs concurrently with axonal ectopic
ring and the initiation of allodynia [19]. Second, there is an intracellular

regulation of the Na channels that allows the channels to remain open lon-
ger and create more hypersensitivity and even spontaneous ring of dam-
aged neurons [20]. The third way involves the interruption of axonal
transport. If an axon is transected [21], exposed to certain toxins, or un-
dergoes demyelination [22,23], then the axonal transport system responsible
for moving Na channel proteins from the cell nucleus to the axon sensory
nerve endings is disrupted. This results in accumulation of transport vesicles
at the damaged region. Furthermore, once damage occurs, neuromas (aber-
rant nerve regeneration) may form. Transport vesicles and Na channel
proteins build up in the multiple sprouting endings of the neuroma endbulb
because they can no longer go to their original destination. Apparently, the
Na channels are then inserted into the cellular membrane where the integ-
rity of the myelin sheath has been compromised or in the neuroma causing
an abnormal, elevated concentration of these channels. The membrane hy-
persensitivity is directly dependent upon the concentration of Na channels
[14]. The concentration of Na channels and hypersensitivity of the neuro-
nal membrane after nerve injury is increased, resulting in spontaneous or
easily stimulated repetitive ring of nociceptive neurons, causing the neuro-
pathic pain.
An understanding of the mechanisms of neuropathic pain can provide the
clinician/scientist with a basic rationale for treatment. Because the patho-
genesis of neuropathic pain has not been determined, the practitioner
must be aware of the various classes of pharmacotherapeutic agents that
have been suggested to provide relief in selected cases. Pharmacotherapy
for neuropathic pain encompasses a variety of agents with analgesic poten-
tial. A systematic approach to drug trials and ongoing assessment by a re-
sponsible, informed practitioner is key to successful control of
neuropathic pain. Diverse agents in numerous classes may be used eec-
tively in the heterogenous population with pain of neuropathic nature. Ad-
juvant analgesics are drugs that have primary indications other than pain
but may be analgesic in specic circumstances. Some of the medications
that have been suggested to be eective are included in Box 2.
Because the synaptic cleft is not predictably involved in the etiology of
neuropathic pain, it is not surprising that drugs that inhibit synaptic trans-
mission are many times ineective; however, these drugs should remain
a consideration. Examples of drugs that act at the synaptic cleft include clo-
nidine or benzodiazepines. Rather, the membrane-stabilizing drugs, such as
the anticonvulsant drugs (eg, carbamazepine, lamotrigine, oxcarbazepine,
and phenytoin), are more predictably eective because they suppress the hy-
perexcitability of the axonal membrane [24]. Tricyclic antidepressants, such
as amitriptyline, may be eective at low dosages because they also work as
membrane stabilizers in addition to their trans-synaptic eects [25].
Local anesthesia has been used as diagnostic aid in the evaluation of the
patient who has orofacial pain. Devor [13] has suggested that a positive
Box 2. Adjuvant analgesic drugs that may be used

in the treatment of neuropathic orofacial pain
Antidepressants
Tricyclic antidepressants
Amitriptyline
Nortriptyline
Imipramine
Serotoninnorepinephrine selective reuptake inhibitors
Venlafaxine
Duloxetine
Anticonvulsants/antiepileptic drugs
Carbamazepine
Oxcarbazepine
Phenytoin
Gabapentin
Pre-gabalin
Lamotrigine
Topiramate
Tiagabine
Levetiracetam
Clonazepam
Valproic acid
Zonisamide
Local anesthetics
Muscle relaxants
Lioresal
Tizanidine
response to local anesthetic provides validation of the axonal membrane eti-

ology for neuropathic pain. Local anesthetics have a membrane-stabilizing
eect and provide an additional treatment consideration for neuropathic
pain. One study demonstrates the eectiveness of lidocaine for the suppres-
sion of nerve growth factor and the resultant sympathetic neurite sprouting
in the dorsal root ganglion and in peripheral nerves [26]. This could suppress
pain connections in the dorsal root ganglion and the hypersensitivity periph-
erally. Systemic lidocaine also was demonstrated to have a selective depres-
sion of C-ber activity in the spinal cord, which could aect transmission of
certain neuropathic pain types [27]. In summary, lidocaine can be applied
topically with other medication in transdermal preparations, injected lo-
cally, or administered systemically for therapeutic benet and not just for
short-term pain relief [28,29].
Trigeminal neuralgia
Trigeminal neuralgia (TN) is a neuropathic orofacial pain originating in
one or more branches of the Vth cranial nerve sensory distribution. TN can
be idiopathic or secondary to demyelinating diseases (eg, multiple sclerosis)
or the result of trauma. The pathology involves the structures of the neurons
rather than the peripheral structures innervated by them.
One study reported the results for visits to neurology practice and found
that the three main neuropathic pain-related diagnoses were postherpetic
neuralgia, TN, and diabetic neuropathy [30]. In this study, 7.95% of the pa-
tient referrals were found to be for neuropathic pain; TN was one of the
main diagnoses. The incidence of trigeminal neuralgia has been reported
to be 2 to 27 individuals per 100,000 of the general population [31,32].
The larger number reported was generated from actual patient visits in
the United Kingdom from a review of over 6 million visits to primary
care physicians and not purely referrals to neurology-based practices. If
this last report is accurate, then TN may be markedly under diagnosed.
Women are reported to experience TN with a greater frequency then are
men. The onset of idiopathic TN occurs typically after 50 years of age and
rarely occurs before the age of 30. Dentistry plays an important role in recog-
nizing TN in its early stages because this condition can mimic dental pain,
prompting dental approaches before a denitive diagnosis is made.
TN occurs primarily in the maxillary or mandibular divisions of the tri-
geminal nerve distribution unilaterally and may involve one or both divi-
sions. It is rarely expressed in the ophthalmic division. Individuals who
suer from TN report a sharp, shooting, or lancinating pain that lasts
from a few seconds to 2 minutes. These paroxysms may occur at intervals
or nearly continuously. The patient may enter a refractory period that can
last for minutes to hours where the pain cannot be triggered. TN can go
into a period of remission, may never return, or may be re-expressed in
an even more refractory state. This pain often is associated with a trigger
zone that, when stimulated, triggers the lightening boltlike pain with a light
touch or a light breeze on the face. Other commonly reported triggers are
chewing, talking, swallowing, brushing the teeth, combing the hair, putting
on make-up, or washing ones face. Some individuals have multiple trigger
zones, whereas others have spontaneous pain with no identied trigger
zones. The most common trigger zones are lateral to the ala of the nose (na-
solabial fold area) in the maxillary distribution or near the commissure of
the lip in the mandibular distribution. Trigger zones can include intraoral
sites including teeth, mucosa, and the tongue. One study reported that
64.5% of patients presented with an intraoral trigger zone [33]. TN can refer
pain to the teeth. This can make the diagnosis dicult because dental pulpal
pain often mimics neuropathic pain. Failure to address the proper diagnos-
tic entity results in well intentioned, but misdirected, care and perpetuation
or exacerbation of the pain. The same study reported that 31 of 48 patients
underwent dental procedures for their facial pain before TN was diagnosed
[33]. Along with this lightening boltlike pain, 15 to 20% of patients who
have TN also exhibit sensory loss in the aected trigeminal division, which
is rarely reported [34]. This can lead to confusion in diagnosis and prompt
multiple tests to rule out other entities discussed later in this article.
Pre-trigeminal neuralgia
The diagnosis if TN may take months or more to conrm because the
condition may be initially expressed as pre-trigeminal neuralgia (PTN). At
this stage, the condition may present with a dull aching pain (a toothache
or sinus-like pain) with a sporadic sharp, lancinating component. The
pain is of spontaneous onset but with no specic trigger zone. Pain may
be triggered by routine activity such as chewing, drinking hot or cold liq-
uids, tooth brushing, yawning, or talking. The duration of PTN-related
pain may be minutes to hours or in some cases constant, in comparison
to a duration of seconds to minutes characteristic for classic TN. The
pain is likely to decrease with the use of diagnostic anesthesia. In PTN,
the dierential diagnosis must include neoplasm, atypical odontalgia, odon-
togenic pain, lower-half headache, sinusitis, myofascial pain, temporoman-
dibular joint dysfunction, and osseous pathology due to the overlap of
symptoms. PTN typically progresses to classic TN.
The mechanisms associated with TN and PTN have been debated for
many years. There must exist a malfunction at the peripheral or central neu-
ronal components of the trigeminal system. One theory suggests a demyelin-
ation of the root of the trigeminal nerve by vascular compression in the area
[34]. Intracranially, an artery may rub against the trigeminal axons, causing
a hyperexcitability in the primary aerent neurons and a decreased ecacy
of the inhibitory controls. One author suggests that this creates an increased
spontaneous ring of the wide dynamic neurons in the subnucleus caudalis
(nociceptive neurons) and hypersensitivity (lowering of the threshold) of the
low-threshold mechanoreceptors in the subnucleus oralis [35]. Another the-
ory proposes nerve entrapment at the foremen rotundum or foramen ovale
and suggests that this phenomenon may explain the right-sided (3:2) predi-
lection of TN [36]. The result is that low-threshold mechanoreceptors re
spontaneously or when stimulated by what would normally be a nonpainful
stimulus, such as light touch. The action potential is carried by Abeta bers
(large-diameter, heavily myelinated bers that carry nonpainful sensations
and proprioception) that trigger a paroxysmal ring of the Adelta bers
(lightly myelinated nociceptive bers), causing the electrical-like pain that
is characteristic of TN.
Treatment of TN can be divided into two primary modalities: pharmaco-
therapy and surgical. Pharmacotherapy generally involves using the mem-
brane-stabilizing anticonvulsant class of medications. Carbamazepine is
the gold standard, but multiple adverse eects frequently prohibit its use.
Other anticonvulsants, including oxcarbazepine, lamotrigine, gabapentin,

and pregabalin, may be ecacious. Other adjuvant medications in the anti-
spasmodic, muscle relaxants, antidepressants, and local anesthetic drug clas-
sications can be used in combination with the primary medication.
TN can also be treated by neurosurgery. Surgical approaches may be nec-
essary if pharmacotherapy becomes ineective or is medications are not tol-
erated. In some cases, surgical intervention should be the rst line of
treatment. One eective surgical treatment is microvascular decompression,
or the Janetta procedure. Entry is made into the cranium behind the mastoid
process, and a synthetic material is placed between the trigeminal rootlets
and the vascular structures found to be compressing the nerve. Studies re-
port that a 90 to 96% incidence of vascular compression is identied in pa-
tients undergoing the microvascular decompression procedure [37]. One
study reported 80% complete pain relief over a 20-year period [38].
Other surgical options involve ablation of the neurons in the trigeminal
ganglion responsible for the patients pain. This can be accomplished several
ways. An instrument is inserted through the cheek and uoroscopically di-
rected through the foremen ovale into the trigeminal ganglion. Once the in-
strument is in place, the patient is awakened to conrm which specic area is
responsible for the pain. The patient is reanesthetized, and the rootlets in the
area are ablated. Three techniques are used for this type of procedure: radio-
frequency thermocoagulation, glycerol, and balloon (mechanical) compres-
sion. These procedures have been reported to provide 90% relief [3941]
that is often immediate. Potential adverse eects include anesthesia, pares-
thesia, hemorrhage, infection, or anesthesia dolorosa (ongoing pain in the
anesthetized area). Gamma knife radiosurgery is a relatively new approach
that uses stereotactic surgery of the trigeminal ganglion targeting the oend-
ing aerent neurons with columnated gamma rays. This technique is fast
and minimally invasive; however, it demonstrates a slow onset of pain relief,
sometimes requiring months to provide full benet.
As compared with idiopathic TN, traumatic secondary TN has a known
cause: trauma to one or more of the divisions of the trigeminal nerve. This
trauma can be associated with a surgical procedure that violates the myelin
sheath of the nerve or any other overt trauma that causes nerve injury. The
prevalence has been noted to be mild in 32% and disturbing in 3% of
cases after orthognathic surgery [42]. The incidence of inferior alveolar
nerve damage after 3rd molar removal was reported to be 5.5% at 24 hours,
3.9% at 7 to 10 days, and 0.9% after 1 year [43].
There have been case reports of neuropathic pain and secondary TN after
the placement of implants, endodontic instruments, endodontic lling ce-
ments, or hydroxyapatite into the mandibular canal resulting in damage
to the inferior alveolar nerve. Local anesthetic injections have been known
to damage the lingual nerve or the inferior alveolar nerve. Clinical presenta-
tion involves patients often reporting numbness, tingling, or sharp, lancinat-
ing, or burning pain. In the aected peripheral region of pain, the skin,
mucosa, or gingiva may exhibit a total sensory loss (anesthesia) or a partial

sensory loss (paresthesia) to sharp and dull testing. MRI T2-weighted imag-
ing can aid in the diagnosis of peripheral nerve damage. A hyperintense sig-
nal from gadolinium-enhanced axonal edema makes peripheral damage
visible [44].
Neural damage can cause pain, but how this occurs is yet to be deter-
mined. One study demonstrated the importance of C-ber involvement in
stimulus-induced and spontaneous types of neuropathic pain conditions
[44]. An increase of neuropeptides (pain modulatory substances), such as
Substance P, calcitonin gene-related peptide, and vasoactive intestinal poly-
peptide, have been shown to be expressed as a result of injuries to the lingual
or inferior alveolar nerves. These same neuropeptides can invoke changes at
the injury site by increasing the rate of discharge of the neuron and at the
trigeminal ganglion involving sodium channels and certain enzymes [8].
Treatment usually involves surgical repair of damaged nerves. Microsur-
geries can be attempted to the lingual or inferior alveolar nerves. If the dam-
age is extensive, neural grafts may be necessary. Time is of the essence. Once
damage has been conrmed, surgical intervention needs to be accomplished
within a few months for optimal treatment outcomes. Finally, pharmaco-
therapy involving the antiepileptic drugs may be needed as adjunctive treat-
ment (see Box 2). In some injury sites involving neuroma formation,
corticosteroid injection can reduce some of the mechanically induced hyper-
activity of that branch of the trigeminal nerve [45].
Atypical odontalgia/non-odontogenic toothache

Atypical odontalgia/non-odontogenic toothache is a condition that is as-
sociated with constant pain in a tooth with no obvious source of local pa-
thology. The typical age of occurrence ranges from 25 to 65 years, with
a mean age of 48 years. Molars are aected at 58%, premolars at 26%,
and incisors at 10%. The maxilla was found to be involved two times
more often than the mandible. The pain was typically reported to be mod-
erate in intensity, with a rating of 46/100 on the VAS scale [46].
Clinically, atypical odontalgia presents as a continuous pain in a particu-
lar tooth that is unchanging for at least for 3 months. Radiograph reveals no
pathology. Diagnostic anesthetic response is equivocal and may result in
resolution of the pain for the duration of anesthetic eect in one instance
but not another [46]. The tooth exhibits hyperesthesia demonstrated by
a positive response to percussion, sensitivity to cold, or pain associated
with chewing. Along with the clinical presentation, there are associated fea-
tures, such as depression, oral dysesthesias, and excessive concern with oral
hygiene [47]. No studies have supported psychopathology as the primary or
sole etiology in this condition.
There is no dened mechanism for this disorder. Theories have suggested
vascular mechanisms, sympathetic dysregulation, psychologic mechanisms,
or a neural pathology. This poses a problem because the patient perceives

pain in a tooth and can be frustrated with the lack of resolution that dental
approaches provide. A diagnosis of exclusion must be made before success-
ful treatment can be rendered or, in the case of non-odontogenic toothache,
no dental treatment at all. Tricyclic antidepressants and benzodiazepines
have been used with equivocal results.
Post-herpetic neuralgia
Post-herpetic neuralgia (PHN) is a neuropathic pain that persists after
the outbreak of the herpes zoster virus (HZV). The varicella virus is respon-
sible for the primary infection and is the cause of chicken pox, which is seen
mostly in young children [4850]. The rash associated with HZV presents
shortly after hyperesthesia or dysesthesia is expressed, usually involving
the scalp, face, and trunk. It is estimated that 95% of the American popu-
lation will have been exposed to the HZV by adulthood, with approximately
four million cases reported each year [51].
After active infection, during the latency stage, the varicella virus goes
through a morphologic transformation referred to as the varicella-zoster vi-
rus (VZV) [49]. In this form, the virus migrates to the ganglion of the periph-
eral nervous system. The most prevalent location for the VZV is the dorsal
root ganglion of the thoracic spine, where the virus is located in 55% of
cases. In 15% of cases, the virus is found in the ganglion associated with
the cranial nerves. Of the cranial nerves, the trigeminal (CN V) and facial
nerves (CN VII) are most frequently involved [48,49]. The cervical distribu-
tion of the spinal nerves is involved in 12% of the cases. Of most interest to
the dentist is VZV expressed in the cranial and cervical distributions. Once
the virus reaches the ganglion, it may remain dormant indenitely. The virus
may be activated by some trigger, which in most instances is unknown.
Once reactivated, the condition is referred to as shingles. Suspected trig-
gers are stress (physical or emotional), colds, spinal cord injury, steroid use,
a compromised immune system, use of immunosuppressants, and cancer
[49,52]. The clinical course of shingles is similar to chicken pox. In contrast
to chicken pox, the herpes zoster virus cannot be contracted from exposure
to the rash [53]. Shingles may present without vesicle formation (Zoster Sine
Herpete), making diagnosis problematic. Shingles is a severe and debilitat-
ing condition that aects over 500,000 people per year in the United States
[51]. It has been reported that there are over 9000 hospitalizations per year,
many with viral pneumonia, related to the zoster virus [51]. Disseminated
shingles can result in blindness and deafness [51].
In the trigeminal system, the virus may be expressed in any of the three
divisions alone or in combination [48]. The ophthalmic branch is most com-
monly involved. Cervical nerve involvement usually follows the C-3 and C-4
distribution. Although zoster can involve more than one nerve distribution,
it generally is expressed unilaterally [48]. Complications of a zoster infection
include myelitis, meningoencephalitis, systemic toxicity, bacterial sepsis, vi-

ral pneumonia, and postherpetic neuralgia.
Reactivation of the dormant virus

When triggered, the herpes zoster virus invades the nerves and ganglion
of the peripheral nervous system. If the immune system becomes suciently
impaired, an intense necrotizing reaction causing nerve injury associated
with glutamate receptor-mediated excitotoxicity ensues [54]. This central
and peripheral nerve damage is the primary cause of the pain experienced
in PHN. PHN may present in the exact area as the pain and rash of the shin-
gles or may encompass larger or smaller zones. Descriptors of the pain in-
clude deep, aching, burning, stabbing, itching, electrical, unbearable, and
re under the skin [55]. Many individuals who experience PHN report
that stimuli such as light touch, wind, or temperature change causes severe
pain [56]. About 87% of patients who have PHN experience allodynia, hy-
peresthesia, dysesthesia, or anesthesia [56]. Such debilitating pain may cause
poor sleep and result in a compromise in activities of daily living. Social iso-
lation due to the severe pain is likely a major reason for the common nding
of depression and anxiety in those who suer with PHN.
The incidence of PHN increases with age [50,55]. On average, one in ve
people who have shingles develop PHN. The older one is when an outbreak
of shingles occurs, the greater the likelihood of developing PHN [48]. At the
age of 55, approximately one in four individuals develops PHN. At age 60,
the incidence increases to two in four; at age 70 or older, three in four are
aicted. There is also some indication that patients who have diabetes
have an increased risk of PHN [51].
There is no cure for PHN. Therefore, the major focus should be on pre-
vention. This fact led the FDA to approve a vaccine for VZV in 1995. The
eectiveness of the vaccine preventing chicken pox is between 70 and 90%.
However, the vaccine is of limited quantity due to the lack of a suitable an-
imal model [57]. Because of the large number of previously HZV-infected
cases, there exists a high probability of the development of shingles and sub-
sequently PHN. This fact mandates that other approaches to management
of the pain associated with PHN be identied.
There are a number of modalities available to address PHN pain, includ-
ing oral pharmacotherapy, nerve blocks, topical medications, electrical stim-
ulation, and complementary alternative treatments (eg, acupuncture and
nutrition). Pharmacotherapy is hallmarked by the use of opioids, antivirals,
antidepressants, and anticonvulsants. Famciclovir, valacyclovir, and acyclo-
vir are the most common antivirals that are used during the viral replication
phase and in immunocompromised individuals [50,51,58]. The tricyclic anti-
depressants that have been shown to be of most benet are amitriptyline and
nortriptyline in small doses [59]. Gabapentin, an anticonvulsant, has re-
cently been approved by the FDA to treat PHN [51,60]. Peripheral and
sympathetic anesthetic nerve blocks have provided relief for PHN pain.
Topical medications come in many forms. The lidocaine patch [61,62] is ap-
proved by the FDA for PHN pain. Capsaicin cream (made from the seeds of
hot peppers) has also been used in the management of pain associated with
PHN. Complementary alternative treatments (eg, acupuncture) have been of
limited ecacy in the control of PHN pain. Nutritional supplements (eg, L-
lysine, vitamin C, vitamin E, vitamin B complex, zinc, calcium and magne-
sium) can be used to support nerve health and provide protection from free
radicals. Herbals, such as green tea, are used to provide antiviral, antioxi-
dant, and anti-inammatory support. Licorice has limited benet as a topical
agent [53].
Summary
Based upon current understanding of neuropathic orofacial pain, success-
ful management is dependent upon recognizing several basic principles.
1. Neuropathic orofacial pain represents a number of subcategories of
conditions that are associated with a primary lesion or dysfunction in
the nervous system.
2. Neuropathic pain conditions are many times overlaid with psychosocial
issues.
3. The primary means of management of most neuropathic orofacial pain
conditions is through rational pharmacotherapy.
4. Limit the use of invasive and irreversible approaches to cases where
there is a high probability that the procedure will eliminate or signi-
cantly reduce the complaint.
5. Do not escalate physical treatments without comprehensive re-evalua-
tion, which should include psychological and behavioral aspects.
5. Ongoing pain can become a disease in and of itself.
6. Complete and accurate diagnosis on a case-specic basis provides for
the development of the most ecacious individualized approach to care.
7. Many cases of neuropathic orofacial pain are best managed by a multi-
disciplinary team involving dentists, neurologists, neurosurgeons, clini-
cal and health psychologists, and other health care disciplines.
8. The health care professional must be aware of the existence of comorbid
conditions and address them appropriately to optimize treatment
outcomes.
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Dent Clin N Am 51 (2007) 225243
Four Oral Motor Disorders: Bruxism,

Dystonia, Dyskinesia and Drug-Induced
Dystonic Extrapyramidal Reactions
Glenn T. Clark, DDS, MS*,
Saravanan Ram, BDS, MDS
Department of Diagnostic Sciences, Orofacial Pain and Oral Medicine Center,
University of Southern California School of Dentistry, 925 West 34th Street,
Room B-14, Los Angeles, CA 90089-0641, USA
Four oral movement disorders

The literature is replete with articles that discuss motor disorders, such
as Parkinsons disease, Bells palsy, essential tremor, poststroke paralysis,
dystonia, and dyskinesia. The focus of this article is on those motor disor-
ders that are known to aect the masticatory system and its adjacent mus-
cles. The term orofacial motor disorder (OMD) encompasses a spectrum
of movement aberrations, both hyperactive and hypoactive, which involves
the muscles of the orofacial complex and are innervated by cranial nerves V,
VII, and XII. OMDs generally present as localized problems that aect only
the masticatory system, but they are driven by alterations in central nervous
system (CNS) functioning. Dentists must be able to recognize and become
involved with management of these problems, because such behaviors cause
pain and dysfunction of the jaw and interfere with needed dental care on
patients [13].
The most common OMDs are sleep bruxism and sustained habitual
forceful clenching (day or night). In addition to bruxism, this article reviews
three other vexing oral motor disorders: focal orofacial dystonia, oroman-
dibular dyskinesia, and medication-induced extrapyramidal syndrome
(EPS)dystonic reactions. Table 1 provides a brief denition, the main clin-
ical features, and management approaches that are used for these four
OMDs. When severe, these motor disorders may cause strong headaches,
E-mail address: [email protected] (G.T. Clark).
226 CLARK & RAM
Table 1
Oral motor disorders: dystonia, dyskinesia, bruxism and dystonic extrapyramidal reactions
Oral motor disorders Denition Clinical features Management
Bruxism Sleep bruxism can Dental attrition Pharmacologic
(ICD-9 #306.8) be dened as Tooth pain treatment data not
nonfunctional jaw TMJ dysfunction convincing.
movement that Headaches Most cases treated
includes clenching, with an occlusal
grinding, clicking, appliance, severe
and gnashing of cases treated
teeth during sleep. with botulinum
toxin injections.
Oromandibular Involuntary, Involuntary jaw Pharmacologic
dystonia repetitive, opening. treatment.
(ICD-9 #333.6) sustained muscle Lateral movements Chemodenervation
contraction that of the jaw. with botulinum
results in an Protrusion of the toxin injections.
abnormal tongue. Select use of
posturing of Present during the neurosurgical
a structure. day. treatment.
Depending on the Disappears during
muscle involved, it deep sleep.
may produce Dystonic spasms
a twisting motion increase in
of involved intensity during
structure. stress, emotional
upset, or fatigue.
Orofacial The presence of Facial grimacing. Withdrawal of
dyskinesia excessive, Repetitive tongue neuroleptic
(ICD9 #333.82) repetitive, protrusion. medications or
stereotypic oral Puckering, smacking other oending
movements. and licking of the agent.
lips. Pharmacologic
Side-to-side motion treatment.
of the jaw.
Drug induced Medications and 3 presentations: Withdraw oending
dystonic-type illegal drugs Dystonia drug.
extrapyramidal produce a motor Akathisia Pharmacologic
reactions response that is Parkinsonism trials.
(ICD-9 #333.9) classied better as
an unspecied
extrapyramidal
syndrome
reaction.
damage the temporomandibular joint (TMJ), or create such motor control

diculty that patients are unable to eat and may start to lose weight. These
motor disorders can aect the tongue musculature to such a degree that it
compromises the patients ability to speak clearly. The social embarrassment
that patients must endure aects their daily living; many patients refuse or
strongly avoid leaving their homes. Fortunately, there are various
FOUR ORAL MOTOR DISORDERS 227
medications, including botulinum toxin injections, and surgical interven-

tions that reduce the severity of the OMDs.
Bruxism
The prevalence of chronic bruxism is unknown, because no large, prob-
ability-based, random sample study has been performed using polysomnog-
raphy (which is needed to measure bruxism). Based on a combination of
attrition assessment and reports by parents, spouses, or roommates, it is
estimated that 5% to 21% of the population has substantial sleep bruxism
[4,5]. Many bruxers do not have substantial attrition and many do not make
tooth-grinding sounds during sleep, so sleep partner or parental reports
are not always accurate. The pathophysiology of bruxism is unknown.
The most cogent theory describes bruxism as a neuromotor dysregulation
disorder. This theory proposes that bruxism occurs because of the failure
to inhibit jaw motor activity during a sleep state arousal. There are numer-
ous clear-cut neuromotor diseases that exhibit bruxism as a feature of the
disease (eg, cerebral palsy). The disorder of periodic limb movements is
similar to an OMD, except that it occurs in the leg muscles [6]. There are
many articles that describe the clinical presentation and consequences of
bruxism; most agree that the single most eective way to protect the teeth
from progressive attrition, fracture, or clenching-induced pulpitis is to
fabricate an occlusal appliance and have the patient use it at night [7].
The problem with an occlusal-covering appliance is that it does little or
nothing to stop the bruxism in the long term. Most alter the behavior for
a few weeks when rst used, but this only oers a brief respite from some
headaches and bruxism-induced TMJ derangement or arthritis problems.
In cases in which the disorder is severe and the damaging consequences
are well beyond the teeth, one option is to inject the masseter or temporalis
about every 3 to 6 months to minimize the power of the bruxism activity.
The literature supports this concept; one of the rst reports was by Van
Zandijcke and Marchau [8] in 1990 who provided a brief note on the treat-
ment of a brain-injured patient who exhibited severe bruxism with bo-
tulinum toxin type-A injections (100 U total into the masseter and
temporalis). Seven years later, Ivanhoe and colleagues [9] described the suc-
cessful treatment of a brain-injured patient who had severe bruxism with
botulinum toxin type-A. In this case, the patient was injected with a total
of 50 U to each of four muscles (right and left masseter and temporalis)
for a total of 200 U. Of course, the successful treatment of a single case
of brain injuryinduced bruxism does not make a compelling story for its
routine use in managing bruxism. The story was extended by a more recent
report [10]. The investigators reported on the long-term treatment of 18
cases of severe bruxism with botulinum toxin type-A. These patients all
had severe bruxism, which had been causing symptoms for an average of
14.8 10.0 years and all had no success with previous medical or dental
228 CLARK & RAM
treatment. Similar to previous reports, the masseter muscle was injected with
a mean dose of 61.7 11.1 U per side. The ecacy of these injections was
rated by the subjects as a 3.4 on a scale from 0 to 4 (with 4 being equal to
total cessation of the behavior). The investigators described one subject who
experienced dysphagia as a side eect of the injections. Finally, another
investigator described a young child (age 7) who had severe brain injury
induced bruxism that was treated successfully with botulinum toxin [11].
The primary management method for strong bruxism and clenching is still
a full-arch occlusal appliance, which does not stop the behavior but limits its
dental damage [12]. Fortunately, the most severe cases of bruxism and
clenching now have several motor suppressive medications; in extreme cases,
botulinum toxin injections can be added to occlusal appliance treatment.
Oromandibular dystonia
Oromandibular dystonia is one form of a focal dystonia that aects the
orofacial region and involves the jaw openers (lateral pterygoids and ante-
rior digastrics), tongue muscles, facial muscles (especially orbicularis oris
and buccinator), and platysma. When this occurs in association with bleth-
rospasm (focal dystonia of the orbiculares oculi muscles), it is called Meiges
syndrome [13]. Dystonia is considered present when repeated, often asyn-
chronous spasms of muscles are present. Most dystonias are idiopathic
and the focal form of dystonia occurs 10 times more often than does the gen-
eralized systemic form [14]. The prevalence of all forms of idiopathic dysto-
nia ranges between 3 and 30 per 100,000 [15]. Focal dystonias can be
primary or secondary; the secondary form of dystonias occurs as a result
of a trauma (peripheral or central), brainstem lesion, systemic disease (eg,
multiple sclerosis, Parkinsons disease), vascular disease (eg, basal ganglia
infarct), or drug use [16]. Most dystonias are primary or idiopathic and
demonstrate no specic CNS disease. Of course, various pathophysiologic
mechanisms have been proposed to explain dystonia (eg, basal ganglia dys-
function, hyperexcitability of interneurons involved in motor signaling [15],
reduced inhibition of spinal cord and brainstem signals coming from supra-
spinal input and dysfunction of neurochemical systems involving dopamine,
serotonin, and noradrenaline [14]). All dystonias are involuntary but tend to
be more intermittent than dyskinesias (see later discussion) and are compro-
mised of short, but sustained, muscle contractions that produce twisting and
repetitive movements or abnormal postures [17,18].
One interesting aspect of the involuntary motor disorders is that patients
can control or suppress the movement partially with the use of tactile stim-
ulation (eg, touching the chin in the case of orofacial dystonia or holding an
object in their mouth). This suppressive eect has been called geste antag-
onistique [19]. These tactile maneuvers may lead physicians to the errone-
ous diagnosis of malingering or hysteria. Other examples of sensory tricks
include placing a hand on the side of the face, the chin, or the back of the
head, or touching these areas with one or more ngers, which, at times, will
reduce the neck contractions that are associated with cervical dystonia. With
some dystonias, patients have discovered that placing an object in the mouth
(eg, toothpick, piece of gum) may reduce dystonic behaviors of the jaw,
mouth, and lower face (oromandibular dystonia). Finally, most of the focal
and segmental dystonias only occur during waking periods and disappear
entirely during sleep.
For treatment, there are several medications that can be used to suppress
hyperkinetic muscles (see later discussion). After medications, the other pri-
mary method for treating dystonia is chemodenervation using botulinum
toxin. In 1989, Blitzer and colleagues [20] rst described the injection of bot-
ulinum toxin for oromandibular dystonia. They described injecting many of
the orofacial muscles in oromandibular dystonia and claimed that masseter
and temporalis injections helped with suppressing the overall oromandibu-
lar dystonia. These early reports did not specically look at tongue move-
ment changes nor were tongue botulinum toxin injection performed. In
1991, Blitzer and colleagues [21] described the rst use of botulinum toxin
in patients who had lingual dystonia, but cautioned clinicians that dyspha-
gia was a problem in some of their cases; unfortunately, doses and injections
sites were not described carefully. In 1997, Charles and colleagues [22]
reported on nine patients who had repetitive tongue protrusion that resulted
from oromandibular dystonia or Meiges syndrome. They were treated
with botulinum toxin injections into the genioglossus muscle at four sites
by way of a submandibular approach. Six of these patients were helped,
and the average dose injected was 34 U, which produced a 3- to 4-month
eect. Clearly, there is a need to explore when, where, and to what degree
botulinum toxin may become useful in the management of the patient
who has galloping tongue or tongue-based severe dyskinesia. There are
many variations of oromandibular dystonia, but one common one is invol-
untary jaw-opening dystonia. One complication of jaw-opening dystonia is
that the TMJ can become locked physically in the wide-open position, so
that even after the dystonic contraction stops, the jaw will not close easily.
In 1997, Moore and Wood [23] described the treatment of recurrent, invol-
untary TMJ dislocation using botulinum toxin A. The injected target was
the lateral pterygoid muscle, and they injected each lateral pterygoid using
electromyographic guidance. The investigators described that the eect
lasted for 10 months. The lateral pterygoid is the muscle that is most respon-
sible for opening; it is a dicult injection, which has a high potential for
misplacement of the solution into other adjacent muscles.
Dyskinesia
Risk factors for the development of tardive dyskinesia are older age,
female sex, and the presence of aective disorders [24]. For spontaneous
dyskinesias, the prevalence rate is 1.5% to 38% in elderly individuals,
230 CLARK & RAM
depending on age and denition. Elderly women are twice as likely to de-
velop the disorder [25]. When this disorder is associated with a drug use,
the medications that are implicated most commonly are the neuroleptic
medications that are now in widespread use as a component of behavioral
therapy. The prevalence of drug-induced dyskinesia (tardive form) is
approximately 15% to 30% in patients who receive long-term treatment
with neuroleptic medications [26]. These medications chronically block do-
pamine receptors in the basal ganglia. The result would be a chemically-in-
duced denervation supersensitivity of the dopamine receptors which leads
to excessive movement; however, other neurotransmitter abnormalities in
g-aminobutyric acid (GABA)ergic and cholinergic pathways have been sug-
gested. There are isolated reports in the literature that implicate dental treat-
ment as a factor in the onset of spontaneous orofacial dyskinesia. Orofacial
dyskinesia occurs as involuntary, repetitive, stereotypical movement of the
lips, tongue, and sometimes the jaw during the day [27,28]. Sometimes the
dyskinesia is induced by medication (tardive) or it can occur spontaneously.
The spontaneous form of dyskinesia often aects the elderly. Typically, the
tardive form of dyskinesia occurs in mentally ill patients who have a long-
term exposure to medications that are used to treat the mental illness [29].
By denition, tardive dyskinesia requires at least 3 months of total cumula-
tive drug exposure, which can be continuous or discontinuous. Moreover,
the dyskinesia must persist more than 3 months after cessation of the med-
ications in question. Most dopamine receptor antagonists cause oral tardive
dyskinesia to one degree or another. The typical antipsychoticsdand in re-
cent years, even the atypical antipsychoticsdincluding clozapine, olanza-
pine, and risperidone were reported to cause tardive dystonia and tardive
dyskinesia. No adequate epidemiologic data exist regarding whether any
particular psychiatric diagnosis constitutes a risk factor for the development
of tardive reactions to medications; however, the duration of exposure to
antipsychotics that is required to cause tardive reaction is from months to
years. Exposure to antipsychotics need not be long, and a minimum safe
period is not apparent. This duration of neuroleptic exposure seems to be
shorter for women. A longer duration of exposure to neuroleptics does
not correlate with the severity of the reaction. Treatment of orofacial dyski-
nesia is largely with medications (see later discussion).
Drug-induced dystonic-type extrapyramidal reactions

There are patients who have developed a medication-induced oral motor
hyperactivity that does not t into the dyskinesia category [30]. These med-
ications and illegal drugs produce a motor response that is classied better
as an unspecied extrapyramidal syndrome (EPS) reaction. EPS responses
typically have three presentations: dystonia, akathisia, and parkinsonism.
Dystonic reactions consist of involuntary, tonic contractions of skeletal
muscles [3133]. Akathisia reactions occur as a subjective experience of
motor restlessness [34,35]. Patients may complain of an inability to sit or

stand still, or a compulsion to pace or cross and uncross their legs. Parkin-
sonian reactions manifest themselves as tremor, rigidity, and akinesia, which
shows as a slowness in initiating motor tasks and fatigue when performing
activities that require repetitive movements (bradykinesia). When a medica-
tion or drug induces a dystonic EPS reaction, it typically involves the mus-
cles of the head, face, and jaw that produce spasm, grimacing, tics, or
trismus. Most of the literature has focused on the more severe acute dystonic
EPS reactions that occur with use of antipsychotic medications. In addition
to the antipsychotics, several antiemetics with dopamine receptorblocking
properties have been associated with tardive dystonia. These include pro-
chlorperazine, promethazine, and metoclopramide. Of course, other less
severe reactions do occur that vary in intensity and even wax and wane
over time. The most commonly reported oending agents that are not
neuroleptics are the selective serotonin reuptake inhibitors (SSRIs) and
the stimulant medications and illegal drugs.
Serotonergic agents that cause extrapyramidal reactions

SSRIs (eg, uoxetine, uvoxamine, paroxetine, sertraline, citalopram, es-
citalopram) are used for depression and a variety of other mental illnesses.
Unfortunately, these drugs are reported to produce the side eect of
increased clenching and bruxism [3639]. Actually the term SSRI-induced
bruxism may not be accurate in that the actual motor behavior does not
present as brief, strong, sleep staterelated contractions as seen in bruxism,
but more of an increased sustained nonspecic activation of the jaw and
tongue musculature. Patients generally describe an elevated headache and
tightness in their jaw, tongue, and facial structures. The best information
available about the eect of SSRI class medications on oromandibular
structures comes from a study in 1999, which examined the acute eects
of paroxetine on genioglossus activity in obstructive sleep apnea [40]. It
found that paroxetine, 40 mg, produced a clear augmentation of peak inspi-
ratory genioglossus activity during non-rapid eye movement (NREM) sleep.
Of course, the recent widespread use of SSRIs is based on a perception that
these drugs have a lower side eect prole than do other categories of anti-
depressant medications (eg, tricyclics and monoamine oxidase inhibitors).
Unfortunately, only case-based literature exists at this time; further poly-
somnographic studies on the motor eects of SSRIs are necessary to dene
prevalence and risk factors and to establish a causal relationship between
SSRI use and oral motor disorders.
Stimulant drugs and other medications that cause extrapyramidal

reactions
Illegal drugs, such as methamphetamine cocaine and 3,4-methylenedioxy-
methamphetamine (Ecstasy), and legal prescription stimulants, such as meth-
ylphenidate, phentermine, pemoline, dextroamphetamine, amphetamines,
232 CLARK & RAM
and diethylproprion, have been reported to induce bruxism and dystonic ex-
trapyramidal reactions [4145]. All stimulant drugs have the potential to
cause extrapyramidal reactions and they are being used in greater numbers
to treat obesity or as stimulants for children who have attention decit hyper-
activity disorder or narcolepsy and even for severe depression [46].
Dierential diagnosis of orofacial motor disorder

The most important aspect of any clinicians skill is the ability to provide
a dierential diagnosis. With the exception of bruxism, all of the other mo-
tor disorders require a neurologic consultation to achieve a denitive diag-
nosis. This includes Bells palsy, essential tremor, the focal and multifocal
dystonias, the dyskinesias, the motor and vocal tics, and hemifacial spasm.
Although the dentist will not be doing this examination, it is necessary to
identify whether a patient has had a correct assessment before participating
in the management of the patient. A proper initial diagnostic work-up for
a movement disorder involves a full clinical examination, including a thor-
ough neurologic examination. This is necessary to rule out the possibility
that the motor dysfunction may be due to a central degenerative, demyelin-
ating, or sclerotic lesion of the nervous system. Depending on the exact na-
ture of the motor disorder, the examining physician may add a thorough
medication and illegal drug history to the work-up. Standard, enhanced,
and angiographic-type MRI will be taken of the brain and spinal cord to
rule in or out a neurologic infarct or tumor or compression of these tissue;
an electromyographic assessment may be ordered to identify specically
which muscles are involved and to assess the patient for a motor nerve or
sensory nerve conduction decit or a peripheral-origin myopathic disease
or motor neuron abnormality; and for the most severe forms of bruxism
and some myoclonic-type bruxism problems, it will be necessary to conduct
a nocturnal polysomnogram, which includes an electroencephalogram. For
the dystonias that aect a specic motor system (eg, blepharospasm or
torticollis), it is necessary to assess that system thoroughly to ensure that
no local infection or neoplastic or arthritic disease is present, to name
only a few of the considerations. For disorders that involve the masticatory
muscles, the tongue, or the perioral muscles, it is necessary for the dentist to
conduct a careful examination to rule out local pathologic entities.
Treatment of orofacial motor disorders

If the dentist chooses to become involved in medicating patients who
have OMDs, it is essential to be familiar with the pharmacodynamic and
pharmacokinetic eects of medications that are prescribed as well as risk/
benet considerations. For dystonia and dyskinesia that have undergone
a conrming medical dierential diagnosis, it is preferable for the dentist
to work in conjunction with a neurologist or psychiatrist who specializes in

movement disorder, because pharmacologic management can be exceed-
ingly complex and frustrating. This frustration is that although the medica-
tions described below can work eectively, more often only a small eect is
seen and side eects can be substantial. Only a dentist who is well versed in
pharmacologic approaches should attempt drug management, albeit this
also should be done with continuing medical interaction. As far as surgical
approaches for movement disorder, these are reserved for the most severe
cases (see later discussion on interventional approaches).
There is no impressive data in the literature that suggest that a medication
(other than botulinum toxin injections) can suppress bruxism reliably for
more than a few days. Behavioral approaches should be addressed by the
appropriate health care provider; they oer some help to patients who are
having an acute stress problem that is inuencing bruxism and clenching
behavior, but again, data on true suppression of bruxism with a straight be-
havioral approach is lacking. Most of the time, the best treatment for brux-
ism is to fabricate an occlusal guard and try to protect the teeth from further
attrition. Botulinum toxin injections are helpful for the more severe motor
disorders, including bruxism.
General medical treatment strategy

For most OMDs, there is no well-dened treatment protocol except to
rule out CNS disease and local pathology and to try one or more of the med-
ications that may be helpful in these cases. If the disorder is severe enough
and focal enough to consider, and the medications are not adequate, botu-
linum toxin injections can be considered. For patients who cannot be helped
with the above, it is reasonable to consider neurosurgical therapy or
implanted medication pumps that can deliver intrathecal medications. The
use of motor blocking injections (botulinum toxin) can be considered.
This method has proven to be most helpful for the focal dystonias and dys-
kinesias. In these disorders, injection of botulinum toxin is used successfully
to block the transmission from the motor nerve to the motor end plate on
the muscle for a period of 2 to 3 months (until the nerve sprouts and recon-
nects to the muscle). In the specic case of bruxism, some of the damage that
is done by this behavior can be mitigated with the use of an intraoral appli-
ance. For hemifacial spasm of spontaneous origin, intracranial surgical
decompression surgery is used occasionally to remove the source of the
irritation on the nerve.
Overview of interventional approaches

Surgical microvascular decompression
This approach can be used for hemifacial spasm if the clinician has deter-
mined that there is a compressive lesion of the facial nerve [47]. The involved
234 CLARK & RAM
blood vessel is lifted o from the facial nerve and often a sponge is placed
between the vessel and the nerve bundle.
Myectomy
If a specic muscle is involved (focal dystonia) or predominates on the
OMD presentation, severing it may oer a solution when the patient has
been refractory to other, more conservative approaches and cannot function.
Blepharospasm may respond to cutting of the orbicularis oculi muscle [48].
Pallidotomy
The globus pallidus is a functional entity within the basal ganglia in the
brain. This procedure involves creating a surgical lesion (localized damage)
in this area of the brain that is involved with motion control; this can be of
value for certain dystonias and torticollis [49]. This is one surgical approach
that is used for managing Parkinsons disease.
Deep brain stimulation

Deep brain stimulation uses an implanted electrode to deliver continuous
high-frequency electrical stimulation to the thalamus, globus pallidus, or
any part of the brain that is involved with the control of movement [50].
In spite of these methods, the prognosis for curing a specic OMD is
poor; however, some of them can be managed successfully with a combina-
tion of education, medications, and selective injections of botulinum toxin.
Treatment of drug-induced dyskinesia and dystonic extrapyramidal

reactions
The general rule is that the oending medication is withdrawn and it is
hoped that the dyskinesia or dystonic reaction goes away [51]. Fortunately,
acute dystonic reactions secondary to neuroleptic drugs are infrequent and
disappear upon discontinuation of the medication; however, this may take
days to months, depending upon the drug, its dose, and the patient. The
same is true for less severe dystonic EPS reactions that are associated
with SSRIs and stimulant drugs.
If the suspected medication cannot be stopped or if the motor hyperactiv-
ity is severe, the following methods are used to treat the motor hyperactivity:
diphenhydramine, 50 mg, or benztropine, 2 mg intravenously (IV) or intra-
muscularly (IM) [5254]. The preferred route of administration is IV, but
if this is not feasible, IM drug administration can be used. Finally, amanta-
dine, 200 to 400 mg/d by mouth [55], and diazepam, 5 mg IV [56], have been
shown to be eective for recurrent neuroleptic-induced dystonic reactions.
Some patients who have SSRI-induced dystonic EPS have relief when the
dosage of SSRI or the other stimulant drug is reduced (eg, uoxetine changed
from 20 mg/d to 10 mg/d). Other patients respond to the addition of buspir-
one in dosages of 5 to 15 mg/d [57,58]. Other patients developed bruxism
within the rst few weeks of SSRI therapy; however, they were treated suc-
cessfully with buspirone, 10 mg two to three times daily. Buspirone seems
to be an eective treatment based on a few case reports. This drug may
have an additional benet of relieving anxiety if it is present. It is usually tol-
erated well and carries a low risk for signicant side eects. Finally, switching
to antidepressants that have not been associated with bruxism, such as
mirtazapine or nefazodone, is an option.
Treatment of spontaneous dyskinesias and dystonias

With any new-onset movement disorders without obvious cause, a motor
suppressive medication trial is logical. The commonly used medications are
presented in Table 2. If the disorder is severe enough and focal enough to
consider, and the medications are not adequate, botulinum toxin injections
should be considered. Finally, for patients who cannot be helped with the
above methods, and the scientic evidence to support alternative approaches
is reasonable, consider neurosurgical therapy or implanted medication
pumps that can deliver intrathecal medications. Regarding the prognosis
of motor suppressive medications, a recent meta-analysis of the literature
made several conclusions that should be shared with patients before starting
treatment [59]. First, this review suggested that botulinum toxin has obvious
benet for the treatment of focal dystonias, such as cervical dystonia and
blepharospasm. Second, trihexyphenidyl in high dosages is eective for the
treatment of segmental and generalized dystonia in younger patients. Third,
all other methods of pharmacologic intervention for generalized or focal
dystonia, including botulinum toxin injections, have not been conrmed as
being highly eective according to accepted evidence-based criteria.
Motor suppressive medications

There are multiple motor suppressive medications used in motor disorder
management.
Anticholinergic therapy
The anticholinergic drugs, such as trihexyphenidyl hydrochloride, biper-
iden, or benztropine are the rst line of motor suppressive medications used
for dystonia, although they are only partially eective when compared with
botulinum toxin injections [60,61]. It is critical to start at a low dose and in-
crease the dose very slowly to try to minimize the adverse eects (dry mouth,
blurred vision, urinary retention, confusion, memory loss).
Gamma-aminobutyric acid receptor agonist therapy

Baclofen is a GABA-ergic agent that is used in spasm [62]. The starting
dosage is 10 mg at bedtime. The dosage should be increased by 10 mg
Table 2
236
Medications used for management of hyperkinetic motor disorders
Drug Group Starting dose Usual dose Indications Receptor action
Trihexyphenidyl Cholinergic 1 mg/d 615mg/d Idiopathic parkinsons, Antagonizes
HCl (Artane) antagonists extrapyramidal acetylcholine
reactions, primary receptors
dystonias
Benztropine Cholinergic 1 mg bid 6 mg/d Parkinsonism, Antagonizes
(Cogentin) antagonists extrapyramidal acetylcholine and
reactions, acute-onset histamine receptors
secondary dystonias
Biperiden Cholinergic 2 mg tid 16 mg/d Parkinsonism, Antagonizes
(Akineton) antagonists extrapyramidal acetylcholine
disorders receptors
CLARK & RAM

Baclofen (Lioresal) GABA agonist/ 10 mg/d 3080 mg/d Spasticity Mechanism unclear,
antispasmodic but most likely
a GABA eect
Clonazepam GABA agonist/ 0.25 mg/d 14 mg/d Seizures, absence Binds to
(Klonipin) tricyclic anxiety, panic benzodiazepine
antidepressant disorder, periodic leg receptors and
movements, neuralgia enhances
GABA eect
Tiagabine Anticonvulsant 4 mg/d 832 mg/d Partial seizures GABA reuptake
(Gabitril) inhibitor
Buspirone Anxiolytic/hypnotic 7.5 mg bid 2030 mg/d Anxiety Nonbenzodiazepine,
(Buspar) but mechanism
unclear
Amantadine Antiviral/ 100 mg bid 100300 mg/d Inuenza A, Mechanism unclear
(Symmetrel) antiparkinsonian extrapyramidal
reactions,
parkinsonism
Carbi/levodopa Antiparkinsonian 25100 mg tid 2002000 mg/d Parkinsons Inhibits peripheral
(Sinemet) associated dopamine
tremor decarboxylation,
dopamine precursor
Diphenhydramine Antihistamine 25 mg tid 400 mg/d Dystonic Antagonizes central
(Benadryl) reactions and peripheral H1
receptors
FOUR ORAL MOTOR DISORDERS

(nonselective)
Clonidine a-2 adrenergic 0.1 mg bid 0.3 mg bid Shown helpful Stimulates a-2
(Catapres) agonist for tardive adrenergic receptor
dyskinesia
Botulinum toxin Neuromuscular 2050 U per large Max: 200 units every Focal dystonia Blocks release of
type A blocker jaw closer muscle 3 months acetylcholine from
(Botox) motor end plate
Abbreviations: bid, twice a day; Max, maximum; tid, three times a day.
237
238 CLARK & RAM
each week to a maximum of 30 mg three or four times daily. The best data
for baclofen is not for oral medications, but for intrathecal injections of
baclofen that are delivered with an implantable pump [63,64]. The main
side eects include drowsiness, confusion, dizziness, and weakness. Finally,
a recent report suggests that tiagabine, a GABA reuptake inhibitor that is
used as an adjunctive anticonvulsant treatment for partial seizures, can be
helpful in bruxism reduction [65]. The dosages of tiagabine that are used
to suppress nocturnal bruxism at bedtime (48 mg) are lower than those
that are used to treat seizures.
Benzodiazepine therapy
Benzodiazepines can be eective for suppression of focal, segmental, and
generalized dystonia [66]. They bind to a specic benzodiazepine receptor on
GABA receptor complex, which increases GABA anity for its receptor. No
study has found a signicant dierence between the various benzodiazepines
and clonazepam, which has been widely used in movement disorders. The
starting dose for clonazepam is 0.25 mg at bedtime and gradually increasing
the dosage to a maximum of 1 mg four times daily. The main side eects
include drowsiness, confusion, trouble concentrating, and dizziness.
Dopamine therapy
A specic subset of dystonias that have an onset in childhood was shown
to respond remarkably well to low-dosage L-dopa, such as carbi/levodopa.
These dystonias are referred to as dopa-responsive dystonias (DRD), and
have been shown in recent years to encompass adult parkinsonism, adult-
onset parkinsonism, adult-onset oromandibular dystonia, spontaneously
remitting dystonia, developmental delay and spasticity mimicking cerebral
palsy, and limb dystonia that is not only diurnal but related clearly to exer-
cise [67,68].
Miscellaneous drugs for movement disorder therapy

There are several miscellaneous drugs that have been reported to sup-
press motor disorders. One medication that is used to suppress motor activ-
ity is buspirone, which is a nonbenzodiazepine anxiolytic drug [60,69].
Another drug whose mechanism is unclear is amantadine, which is used
to suppress extrapyramidal reactions [70]. Other drugs that suppress motor
activity are diphenhydramine [71] and clonidine [72].
Skeletal muscle relaxants

There are numerous drugs that are approved by the US Food and Drug
Administration and used for relief of local regional musculoskeletal pain
and spasm, including carisoprodol, chlorzoxazone, cyclobenzaprine
hydrochloride, metaxalone, methocarbamol, and orphenadrine citrate [73].
Generally, these medications are used only for acute clinical proven spasm
and are not recommended for long-term use. This is because the evidence
is weak that these muscle relaxants are benecial for individuals who have
chronic muscle pain that aects the neck and lower back [74,75]. As far
as chronic involuntary oral motor disorders are concerned, these drugs
are ineective and do not play a role in their management.
Botulinum toxin
In 2003, a thorough review of botulinum toxin for oral motor disorders
was published; it described the potential uses and current evidence basis for
using this medication in the orofacial region [76]. The toxin that is used in
botulinum toxin injections is produced by the anaerobic bacterium Clostrid-
ium botulinum. This injectable drug is able to block motor nerve conduction,
and once injected, it suppresses muscle activity for a time period that ranges
from 8 weeks to 16 weeks for botulinum toxin type-A. Any clinician who
has used this medication will testify to its powerful and dramatic eect in
some cases. Unfortunately, this treatment is only palliative. Botulinum
acts by interfering with vesicular exocytosis, which blocks the release of neu-
rotransmitters that are contained within these vesicles. The blockage occurs
when the toxin enters the nerve and cleaves proteins that are needed for the
docking and release of the vesicle contents into the synaptic cleft [77]. Ace-
tylcholine is believed to be the main neurotransmitter that is blocked by the
BoNT/A. BoNT/A is manufactured by Allergan, Inc. (Irvine, California), as
Botox [78]. This agent is supplied in vials in a lyophilized form, at a dose of
100 U per vial. The typical expiration date is 24 months when stored at 5
to 20 C. Another serotype, BoNT/B, is marketed by Solstice Neurosci-
ences, Inc. (San Diego, California) as Myobloc. Another BoNT/A formu-
lation, Dysport, is marketed outside of the United States by Ipsen Ltd. in
Europe. All of these preparationsdBotox, Myobloc, and Dysportddier
in formulation and potency; hence, their units are not interchangeable.
Side eects can be divided into site-of-injection side eects and medica-
tion-related side eects. With regard to site-of-injection side eects, the nee-
dles that are used for most injections are small (2730-gauge needles); if the
skin is cleaned properly, then the chances of local hematoma, infection, or
persistent pain in the injection site is extremely low. Medication-related
side eects generally are few, transitory, and tolerated well by patients.
The most common medication-related side eect is adjacent muscle weak-
ness (eg, an inadvertent weakening of the muscles of facial expression or
swallowing when this is not desired). For patients who have had injections
into the lateral pterygoid or palatal muscles, slurred speech with palatal
weakness also is a distinct possibility. In general, these inadvertent weak-
ness complications that are due to local diusion of the drug can and do
occur. Moreover, this complication is technique and dose-dependent [79
81]. A second side eect with botulinum toxin injections of the masticatory
240 CLARK & RAM
muscle is an alteration in the character of the saliva of patients who have not
had direct salivary gland injections. Although this is an uncommon prob-
lem, some patients report that their saliva is diminished and thicker (ie,
ropy saliva); it is more likely with higher doses and for injections around
the parotid or submandibular gland. Obviously, this eect is desired at times
if there is a substantial sialorrhea problem.
In most cases, the above complications are less problematic than are the
untreated original motor disorder and generally do not stop the patient from
seeking additional injections. If the injections are being used primarily to
treat pain secondary to contraction, these complications might be more
bothersome. Fortunately, persistent, more signicant complications are dis-
tinctly rare. For example, systemic complications are uncommon and al-
though several studies have reported a ulike syndrome, particularly after
the rst injection, such symptoms also have been reported following placebo
injection. Finally, some patients develop antibodies to the toxin. It is unclear
exactly what factors predispose to development of antibodies, but some
studies suggest that the risk is increased by higher-dose and more frequent
injections. For this reason, injections are not done more often than once
every 12 weeks.
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Dent Clin N Am 51 (2007) 245261
A Critical Review of the Use

of Botulinum Toxin in Orofacial
Pain Disorders
Glenn T. Clark, DDS, MSa,*, Alan Stiles, DMDb,
Larry Z. Lockerman, DDSc, Sheldon G. Gross, DDSd
a
Department of Diagnostic Sciences, Orofacial Pain and Oral Medicine Center,
University of Southern California, 925 West 34th Street, Los Angeles, CA 90089, USA
b
Oral and Maxillofacial Surgery Department, Thomas Jeerson University,
909 Walnut Street, Third Floor, Philadelphia, PA 19107, USA
c
Temporomandibular Joint/Headache Center, University of Massachusetts Memorial Medical
Center, University of Massachusetts Medical School, 119 Belmont Street,
Worcester, MA 01605, USA
d
University of Connecticut Health Center, Farmington, CT 06030, USA
This paper is divided into two parts; the rst part provides a background
on botulinum neurotoxin (BoNT) for medical uses as well as a description of
how to use it. The second part provides a critical review of the evidence re-
garding the use of BoNT for pain in the orofacial region. This review was
based on published literature gathered from Medline databases. Specically,
the authors looked for papers that were randomized, double-blind, placebo-
controlled trials (RBCTs) that were published in peer-reviewed journals.
Where these were not widely available, they describe the case report and
open-label clinical trialsbased evidence.
Regarding the medical use of BoNT, as soon as it became evident that
victims of food poisoning experienced motor paralysis as a part of their dis-
ease and that the bacterium Clostridium botulinum was responsible, the idea
that a toxin that is produced by this bacteria might have medical uses was
not far behind. It was in the 1920s that BoNT was puried rst [1]. It was
not a single toxin that was produced by this anaerobic bacterium; seven se-
rologically distinct forms were discovered (BoNT/A, B, C, D, E, F, G) [2].
From that point to the point at which the United States Food and Drug As-
sociation (FDA) approved BoNT/A was 60 plus years [3]. Toxin A was
E-mail address: [email protected] (G.T. Clark).
246 CLARK et al
found to be the most potent and longest lasting of these seven toxins, and it
has since proven to be a valuable treatment for focal muscle hyperactivity
disorders (eg, focal dystonias). BoNT/A was approved for use by the
FDA for the temporary treatment of two eye muscle disorders (blepharo-
spasm and strabismus), and for cervical dystonia 1 year later [4]. The injec-
tions clearly reduce the severity of motor contractioninduced abnormal
head position and accompanying neck pain. Also in 2000, the FDA ap-
proved BoNT/B for the treatment of cervical dystonia in patients who devel-
oped BoNT/A resistance. Since then, BoNT/A has been approved for the
treatment of primary axillary hyperhidrosis (excessive sweating) and for
the reduction of deep glabellar lines in the face. Table 1 contains the FDA-
approved use specications for BoNT/A and BoNT/B. BoNT/A is supplied
in vials in a lyophilized form, at a dose of 100 units (U) per vial. The typical
expiration date is 24 months when stored at 5 to 20 C. Another serotype,
BoNT/B, is marketed by Solstice Neurosciences, Inc. (San Diego, California)
as Myobloc. Another BoNT/A formulation, Dysport, is marketed outside of
the United States by Ipsen Ltd. in Europe. All of these preparationsdBotox,
Myobloc, and Dysportddier in formulation and potency; hence, their units
are not interchangeable.
O-label botulinum neurotoxin use

In addition to the above on-label uses, BoNT/A is used o-label in the
orofacial region to help treat primary and secondary masticatory and facial
muscle spasm, severe bruxism, facial tics, orofacial dyskinesias, dystonias,
and even idiopathic hypertrophy of the masticatory muscles. A recent re-
view of the literature describes the muscle hyperactivityrelated indications
for BoNT/A in the orofacial muscles [5]. With the exception of hypertrophy,
the common link for these conditions is that they are involuntary motor hy-
peractivity disorders; although their treatment with BoNT is o-label, they
are similar in pathophysiology to the condition for which BoNT is approved
by the FDA. Even more o-label is the suggested use of BoNT for pain
disorders without a clear-cut motor hyperactivity basis. These pain disor-
ders include conditions, such as chronic migraine headache, chronic daily
headache (CDH), chronic myofascial pain, focal sustained neuropathic
pain, and, more recently, episodic trigeminal neuralgia.
Using a drug o-label sometimes generates interest by the medical, legal,
and federal regulatory communities. O-label drug use is not illegal, and the
FDA recognizes that the o-label use of drugs often is appropriate and, in
time, may represent the standard of practice for a specic condition. The
purpose of establishing an approved or labeled use of a drug by the FDA
is to protect patients from unsafe or ineective drugs; however, it is the pre-
rogative of practitioners to use their professional judgment in providing the
best treatment possible for their patients. O-label use of a medication is not
Table 1
US Food and Drug Administrationapproved (on-label) uses of botulinum neurotoxin
Dosing recommendations (initially always use lower
Disease or condition FDA approval Age limitation dose)a
Blepharospasm, strabismus association with 12/29/1989 Adults (O12 y) Botox: dose is 1.252.5 U (0.05 mL to 0.1 mL at each
dystonia, including benign essential site) injected into the medial and lateral pretarsal
blepharospasm or VII nerve disorders. orbicularis oculi of the upper lid and into the
BOTULINUM TOXIN IN OROFACIAL PAIN DISORDERS

lateral pretarsal orbicularis oculi of the lower lid.
Cervical dystonia in adults to decrease the severity of 12/21/2000 Adults (O16 y) Botox: dose for cervical dystonia is between
abnormal head position and neck pain associated 198300 U IM, divide dose among aected
with cervical dystonia. muscles; use ! 100 U into SCM muscle to
decrease dysphagia risk; duration 3 months.
Myobloc: dose for cervical dystonia is between
25005000 U IM divided among aected muscles.
Cosmetic use for moderate to severe glabellar lines 4/12/2002 Adults (%65 y) Botox Cosmetic: dose is 0.1 ml IM times 5 sites. This
associated with corrugator or procerus muscle solution is injected into each corrrugator muscle
activity. and into the centrally located procerus muscle.
Primary axillary hyperhydrosis: Botox is indicated 7/12/2004 Adults (O18 y) Botox: dose for primary axillary hyperhidrosis is
for the treatment of severe primary axillary 50 U intradermal/axilla; divide dose into 1015
hyperhidrosis that is inadequately managed with injections of 34 U per injection positioned 12 cm
topical agents. apart.
Pediatric dose: safety and eectiveness in children younger than the age of 12 have not been established for blepharospasm or strabismus and younger than
the age of 16 for cervical dystonia or 18 for hyperhidrosis.
Geriatric use: clinical studies of Botox did not include sucient numbers of subjects aged 65 and older to determine whether they respond dierently from
younger subjects. Other reported clinical experience has not identied dierences in responses between the elderly and younger patients. There were too few
patients older than the age of 75 to enable any comparisons. In general, dose selection for an elderly patient should be cautious, usually starting at the low end
of the dosing range, reecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
Abbreviations: IM, intramuscularly; SCM, sternocleidomastoid.
a
Renal and hepatic dosing: not dened.
247
248 CLARK et al
a license to use any product o-label without regard for the published scien-
tic evidence of ecacy. The practitioner who elects to use a drug o-
label bears some inherent liability risk. Legal rulings have suggested that
o-label drug use in itself is not sucient evidence of negligence; however,
the practitioner should do so only when one believes that the o-label use
is outweighed by the potential benet to the patient. In such situations,
the risks and benets should be explained to the patient, and a consent
form (Fig. 1) should be signed by the patient. The clinician also should be
familiar with a reasonable body of scientic evidence that supports the ap-
plication of the drug (in this case BoNT/A) specically for the disorder un-
der treatment. It also is important that the patient be informed that the
expected therapeutic benet may only extend weeks to months, and that
the treatment will need to be repeated to have an ongoing eect.
Fig. 1. Botulinum toxin consent form.

BOTULINUM TOXIN IN OROFACIAL PAIN DISORDERS 249
Mechanism of action
BoNT inhibits the exocytosis of acetylcholine (ACh) on cholinergic nerve
endings of motor nerves [6]. Autonomic nerves also are aected by the inhi-
bition of ACh release at the neural junction in glands and smooth muscle [7].
BoNT achieves this eect by its endopeptidase activity against SNARE pro-
teins, which are 25-kd synaptosomal-associated proteins that are required
for the docking of the ACh vesicle to the presynaptic membrane. It was sug-
gested that when BoNT was used for the treatment of neuromuscular disor-
dersdparticularly focal dystonias and spastic conditionsdpatients reported
a marked analgesic benet [8]. Initially, this benet was believed to be due to
the direct muscle relaxation eect of BoNT; however, various observations
have suggested that BoNT may exert an independent action on peripheral
nociceptors by blocking exocytosis of such neurotransmitters as substance
P, glutamate, and calcitonin generelated peptide (CGRP). In addition, be-
cause BoNT does not cross the bloodbrain barrier, and because it is inac-
tivated during its retrograde axonal transport, the eect is believed to be in
the rst-order sensory nerve and not more centrally [9]. The actual experi-
mental evidence that examines this analgesic claim is presented below.
Training and injection procedures

Training in the use of BoNT/A usually is accomplished by way of short
training programs or preceptorships in the oce of an experienced care-
giver. As with any injected medication, it is imperative that clinicians un-
dergo training that includes knowledge of anatomy, injection techniques,
handling of the materials, side eects, and appropriate dosing, because dif-
ferent dosages are used in the dierent areas of the mouth, face, and neck
for dierent medical conditions. Although the skills to inject BoNT into
a muscle are learned easily, some training in this arena is suggested. Essen-
tially, BoNT is injected in the same manner as are local anesthetics, and
a 23- to 30-gauge needle is placed into the target muscle. Targeting is con-
rmed by palpation in larger muscles. When a muscle is dicult to palpate,
such as the anterior digastric or lateral pterygoid muscles, conrmation of
correct needle position before injection can be conrmed by use of a Tef-
lon-coated monopolar injection needle that also has the ability to record
the electromyographic (EMG) signals from the muscle. This technique re-
quires specic training in the use of an EMG machine. The authors wish
to emphasize that EMG guidance is not a requirement for injecting most or-
ofacial muscles, because they can be injected safely by using palpation con-
rmation of location. Depending on the equipment used, the recording is
displayed on a screen or turned into the sound pattern. The graphic display
or sound increases in amplitude, frequency, or volume when the muscle con-
tracts. To be sure that the practitioner is in the correct muscle, the patient
may be asked to make a specic movement or eort to activate the target
250 CLARK et al
muscle. One can reduce the risk for BoNT dispersion into unwanted adja-
cent sites by using supercial injections, having the patient keep activity
to minimum, and not massaging the area for 4 hours; this allows the toxin
to penetrate mainly the target nerves. Ultrasound, uoroscopy, or CT also
may be used, but is needed rarely for the orofacial muscles.
Injection preparation, dosing, and eect duration

BoNT/A is kept frozen (24 C) in a vial until it is ready to use. The drug
is put into solution, following manufacturers guidelines, by adding normal
saline (preservative-free 0.9% saline solution). Once prepared it should be
used within 4 hours. The preferred syringe is a calibrated 1.0-mL tuberculin
syringe, and the needle selected for injection usually is between 26 and 30
gauge. Skin preparation involves alcohol wipes and dry sterile gauze
sponges. Aspiration before injection is recommended. Usually, dosing is es-
tablished by the diagnosis and reason for use of the toxin, size of the muscle,
and medical conditions or medications. Until studies narrow down all spe-
cics, the nal dilution and dosage used is left to the clinical experience and
discretion of the practitioner. The number of injection sites usually is deter-
mined by the size of the muscle. Theoretically, it may be appropriate to in-
ject more sites with smaller doses, and using more injection sites should
facilitate a wider distribution of BoNT/A to nerve terminals; however, too
many injection sites may cause local injection site pain. The proper targeting
of muscles is a crucial factor in achieving ecacy and reducing adverse ef-
fects from BoNT/A injections. The therapeutic eects of BoNT/A rst ap-
pear in 1 to 3 days, peak in 1 to 4 weeks, and decline after 3 to 4 months.
Adverse events and side eects

BoNT is classied as a Category C drug by the FDA, because its reported
use in pregnant and lactating women is scant. Approximately 1% of patients
who receive BoNT/A injections may experience severe, debilitating head-
aches that may persist at high intensity for 2 to 4 weeks before fading grad-
ually [10]. Care in choosing the injection site and dose used may limit
undesirable muscle weakness. A small group of patients eventually may de-
velop antibodies; this problem generally occurs when patients receive higher
doses, especially at more frequent intervals. Therefore, the FDA-approval
label recommends injecting no more frequently than once every 3 months
and using the lowest eective dose to minimize antibody formation.
Cautions and contraindications

When using BoNT/A, caution must be used when injecting individuals
who have peripheral motor neuropathic diseases or neuromuscular
junctional disorders. Moreover, drugs that interfere with neuromuscular

transmission, such as aminoglycosides, magnesium sulfate, anticholinester-
ases, succinylcholine chloride, polymyxins, quinidine, and curare-like non-
depolarizing blockers, can potentiate the eect of BoNT/A. BoNT/A
treatment is contraindicated in the presence of infection, especially at the in-
jection site and in individuals who have known hypersensitivity to any ingre-
dient in the formulation. Formation of neutralizing antibodies to BoNT/A
may reduce its eectiveness by inactivating the biologic activity of the toxin
and the rate of formation of these neutralizing antibodies in patients who
receive BoNT/A treatment; its long-term eects have not been studied
well. The reformulated BoNT/A has a lower protein content that may de-
crease the risk for antibody formation and the development of resistance.
Patients who have neuromuscular disorders who receive BoNT/A could
have amplied eects of the drug, such as severe dysphagia and respiratory
diculties. Patients who have BoNT/A injections in the cervical region,
tongue, or posterior region of the mouth may experience dysphagia. Rare
cases of arrhythmia and myocardial infarction have been reported. Some
of these patients had pre-existing cardiovascular disease. Caution also
should be exercised when injecting patients who have excessive atrophy or
weakness in target muscle, ptosis, excessive dermatochalasis, deep dermal
scarring, thick sebaceous skin, marked facial asymmetry, and inammatory
skin disorder at the planned injection site. Box 1 contains a preinjection
checklist.
Box 1. Preinjection check list

Appropriate emergency drugs, such as epinephrine, should be
available when a toxin is to be injected.
The practitioner should have an established injection protocol
that includes the specific locations and appropriate doses for
the condition to be treated.
All injection sites should have been evaluated properly. If the
region to be injected has been surgerized previously, potential
anatomic variations should be taken into consideration.
The practitioner must be aware of all medications and
supplements that are taken by the patient to minimize any
effect on the potency of the BoNT/A.
The practitioner should be aware of all medical conditions; vital
signs, such as blood pressure, should be noted before
injecting.
It is strongly recommended that a consent form be explained to
and signed by the patient (see Fig. 1).
252 CLARK et al
Botulinum neurotoxin and experimental pain in animals

Regarding the evidence for BoNT as a pain control agent, it is appropri-
ate to look rst at how BoNT aects experimental pain in animals. Two an-
imal studies examined how the release of pain-inducing neurotransmitters is
suppressed in nociceptive aerents and sensory ganglia neurons by BoNT/A
treatment [11,12]. In another rat model, the eect of BoNT on pain from
nerve bers in the bladder was examined. This was done by lling the blad-
der with a 0.3% acetic acid solution in BoNT/A-treated rats. Rats who had
received BoNT/A previously showed a signicantly decreased CGRP release
at day 7 after the injection compared with control (non-BoNT/A) rats [13].
These neurochemistry studies are supported by an animal pain behavior
study that examined the eect of BoNT on pain involved a subcutaneous
injection of formalin into the paw of a rat [14]. This injection is known to
cause the release of glutamate from the primary aerent neuron, which in-
duces increased paw-licking behavior in the rat. The investigators reported
that preconditioning the animal by giving it a BoNT injection into the paw
before the formalin injection reduced paw licking. They suggested that this
was evidence of a direct analgesic response from BoNT. Finally, in another
pain behavior study, the antinociceptive eect of BoNT/A was examined us-
ing a rat model of carrageenan (1%)- and capsaicin (0.1%)-induced paw
pain [15]. Mechanical and thermal responses were recorded. The investiga-
tors reported on the use of BoNT/A (5 U/kg) that was applied 6 days or
1 day before peripheral carrageenan or capsaicin injections. When used
6 days before injection, enhanced sensitivity to mechanical and thermal
stimuli was reduced signicantly or abolished. Based on these data, it was
suggested that BoNT inhibits trigeminal hyperexcitability by blocking the
antidromic ow of substance P and CGRP. This results in a decrease in pe-
ripheral sensitization of nociceptive bers, which indirectly reduces central
sensitization. Another pain inhibitory eect of BoNT/A may be by blocking
stimulated CGRP release from sensory ganglia neurons [16].
Botulinum neurotoxin and experimental pain in humans

Two recent RBCTs examined experimental pain and BoNT in humans.
These studies show conicting results. A 2002 study specically measured
cutaneous nociception in 50 healthy adult volunteers who received bilateral
subcutaneous forearm injections of 100 units of BoNT/A or placebo [17].
Pain thresholds for heat and cold in the treated skin areas were measured
quantitatively. Quantitative sensory testing was performed before and
4 and 8 weeks after BoNT injection. The heat and cold pain thresholds in-
creased by 1.4 C from baseline to week 4 and by 2.7 C by week 8. In com-
parison, the placebo site showed 1.1 C and 1.2 C changes at weeks 4 and 8,
respectively. A similar trend was seen for electrical-induced pain thresholds,
but none of these dierences was statistically signicant. The investigators
concluded that no strong direct cutaneous antinociceptive eect for

BoNT/A was demonstrated by their study. In contrast, Barwood and col-
leagues [18], in 2000, studied the analgesic eect of BoNT on 16 young chil-
dren (mean age, 4.7 years) for management of their spastic cerebral palsy.
These investigators reported that, compared with the placebo, BoNT/A
injections reduced pain scores by 74% (P ! .003). They did not measure
pain threshold using quantitative sensory testing, and pain measurement
in children this young might be problematic.
Previous systematic review of botulinum neurotoxin for pain

The animal, and, to a lesser degree, the human data that were reviewed in
the preceding two sections provide the underpinnings for the theory that
pain may be reduced by BoNT. It is not known which orofacial chronic
pain disorders might be modulated by BoNT. This question was examined
in a previous systematic review [19]. The reviewers examined published data
on various head and neck pain conditions by performing a thorough search
of the medical literature, striving to nd RBCTs that evaluated the eect of
BoNT on specic conditions. They reported that two RBCTs were found for
cervicogenic headache; however, the results were in conict, and therefore,
nonconclusive. They also identied two studies that addressed chronic
neck pain, but neither revealed signicant ecacy data. Only one small trial
was found that involved temporomandibular disorders (TMD) (N 15 pa-
tients), but no conclusive eect was evident. No RBCT was identied for the
use of BoNT in cluster headache, chronic paroxysmal hemicrania, or tri-
geminal neuralgia. Therefore, the investigators were unable to draw any def-
inite conclusions about the eectiveness of BoNT on these conditions.
Myofascial trigger points

Myofascial trigger points are believed to be the result of abnormal motor
end-plate activity that produces an excessive continuous release of the neu-
rotransmitter ACh [6]. In theory, using neuromuscular blocking agents, such
as BoNT, for myofascial trigger point pain would eliminate the end-plate
dysfunction by blocking the release of Ach, and, thereby, reduce pain. An
open-label case series on 77 patients that was published in 2003 reported re-
duced visual analog scale (VAS) pain levels after using BoNT/A for persis-
tent trigger points [20]. In contrast, in 2006 an RBCT parallel clinical study
examined the eect of BoNT on pain from muscle trigger points [21]. Al-
though BoNT did not reduce motor end-plate activity, it had no better eect
on pain or pain thresholds when compared with isotonic saline. The inves-
tigators concluded that BoNT does not have a specic antinociceptive or
analgesic eect. In 2006, another double-blind, randomized, controlled cross-
over BoNT trial was reported on 31 subjects who had neck and shoulder
254 CLARK et al
myofascial pain [22]. The investigators concluded that there was no dier-
ence between the eect of small doses of botulinum toxin A and those of
physiologic saline in the treatment of myofascial pain syndrome. Finally,
three other randomly assigned, double- or single-blind studies compared
BoNT/A with a control/comparison treatment. The rst of these RBCTs
compared trigger point pain that was treated with BoNT/A versus saline
[23]. The study included 132 patients who had cervical or shoulder myofas-
cial pain with active trigger points; it used VAS pain reports, pressure algo-
metry, and pain medication usage as the outcome measure. The
investigators reported no signicant dierences between the groups. An-
other recent randomized, double-blind, cross-over study compared BoNT/A
with bupivacaine and included 18 patients [24]. The investigators compared
the eectiveness of trigger point injections using the two agents in combina-
tion with a home-based rehabilitation program. After being injected, the
subjects were followed until their pain returned to at least 75% of their
preinjection pain for two consecutive weeks. After an additional 2-week
wash-out period, the subjects received the other treatment injection. Both
treatments were eective in reducing pain when compared with baseline
(P .0067), but there was no signicant dierence between the injected
agents in the duration or magnitude of pain relief, function, or satisfaction.
A third randomized, single-blind treatment comparison study, which evalu-
ated BoNT/A with dry needling and lidocaine injections into cervical myo-
fascial trigger points, was reported in 2005 [25]. This study involved 29
patients. Pain pressure thresholds and pain scores improved signicantly
in all three groups, with a slightly greater response in the groups that re-
ceived lidocaine and BoNT/A. Overall, these RBCTs suggest that BoNT
is no better or longer lasting than are the other standard trigger point based
therapies. Overall, the literature suggests that BoNT is not better or longer
lasting than is placebo or other standard trigger pointbased therapies.
Temporomandibular pain and dysfunction

The rst open-label study for an acceptable size group of patients that
was diagnosed with a temporomandibular disorder occurred in 1999 [26].
This study reported on 15 adult patients who had a nonspecic heteroge-
neous diagnosis of temporomandibular joint pain and dysfunction. All sub-
jects were given BoNT/A, 150 U, divided among the right and left masseter
and temporalis muscles. The investigators reported that jaw pain (VAS) and
muscle tenderness decreased, with no reported side eects. In 2000, these in-
vestigators expanded their data set and reported on a larger case series of 60
patients who had mixed temporomandibular disorders, many of whom
qualied as having chronic tension-type headaches (CTTHs; n 46).
BoNT/A was used under open-label uncontrolled conditions [27,28]. The in-
vestigators reported signicant results for all measured outcomes, except for
maximum bite force. In 2001, another open-label study reported on the ef-
fect of BoNT/A for chronic facial pain in 41 patients who had the diagnosis
of temporomandibular dysfunction [29]. The investigators injected an aver-
age of 200 U of BoNT/A on each side into the jaw closing muscles, and fol-
lowed the patients for an average of 6.7 months. They reported that 80% of
patients improved, with a mean pain reduction of 45% (VAS). One patient
had reversible speech and swallowing diculties. A recent report (also an
open-label case series) looked specically at temporomandibular disk func-
tion in 26 patients [30]. The investigators used BoNT/A (12.5 U) injected
into the lateral pterygoid muscle, although some patients also received injec-
tions into the temporalis, medial pterygoid, and masseter muscles when se-
vere tenderness was noted. Except for clicking of the right joint, all outcome
measures (pain, opening, left temporomandibular joint clicking, headache)
improved.
Open-label case reports do not constitute strong evidence, and all such
preliminary reports need to have RBCTs conducted to assess fully the true
eect of the therapy being examined. The full story that underlies TMD
and BoNT can be better understood by looking at two RBCTs. The rst
involved 90 patients who had a heterogeneous diagnosis of chronic facial
pain, including temporomandibular dysfunction. Sixty subjects received
masticatory muscle injections with BoNT/A, whereas 30 subjects received
a placebo injection [31]. This study was only single-blinded (ie, the injec-
tors knew what substance was being injected), which increases the risk
for inducing bias in the study outcome. Moreover, the technique was
not described clearly and it was unknown whether the investigators in-
jected bilaterally in most patients. If they did and they used 70 U per mus-
cle (medial pterygoid, masseter, temporalis), one must assume that they
applied nearly 400 U of BoNT/A per patient. Ninety-one percent of the
patients who received BoNT/A showed an improved VAS pain score.
The mean change was 3.2 points on a 10-point scale, which was signi-
cantly dierent from the change seen with placebo injections (0.4 points).
In contrast to the above study is another RBCT on jaw muscle pain in
a smaller sample [32]. This second RBCT included 15 women who had
chronic moderate to severe jaw muscle pain. The study was double-blind,
using a total of 150 U of BoNT/A divided between the right and left tem-
poralis and masseter muscles. Data were collected at baseline and at 8, 16,
and 24 weeks after injection. A major dierence compared with the previ-
ous study was that the subjects were crossed over to the comparison treat-
ment after 16 weeks. Five subjects did not complete the study. For the 10
patients who nished, no statistically signicant dierence was found in
pain variables. The investigators concluded that the results do not support
the use of BoNT/A for moderate to severe jaw closing muscle pain. Based
on these two studies, it is not clear whether the eect of BoNT/A injec-
tions for jaw muscle pain, using doses in the 100- to 150-U range, will
be sustained.
256 CLARK et al
Chronic migraine
That patients experienced relief of migraine symptoms as a unexpected
side benet of having BoNT injections for hyperfunctional facial lines was
reported in 2000 [33]. Two additional studies have concluded that BoNT/A
is an eective and safe prophylactic treatment for headache across a range
of patient types [34,35], including migraine of cervical origin [36]. A recent
review of the literature summarized the data on BoNT/A for migraine pro-
phylaxis [37]. Based on a combination of open-label data and three RBCTs
on episodic migraine, it was concluded that BoNT/A is eective in migraine
prophylaxis. Its main eect was to reduce the frequency, severity, and dis-
ability that is associated with migraine headaches. The rst of these studies,
in 2002, examined 123 subjects using a random-assignment, double-blind,
vehicle-controlled approach. All subjects had a history of two to eight mod-
erate-to-severe migraine attacks per month, with or without aura [38]. Dia-
ries were kept during a 1-month baseline and for 3 months following the
injection period. The group that received BoNT/A, 25 U, showed signi-
cantly fewer migraine attacks per month, a reduced maximum severity of
migraines, a reduced number of days of acute migraine medication use,
and a reduced incidence of migraine-associated vomiting [39]. The second
study was less clear-cut and examined 60 patients who had migraines using
an RBCT method. Subjects received BoNT/A or placebo injections. There
were no signicant dierences between the groups with respect to reduction
of migraine frequency, number of days with migraine, and the number of
total single doses to treat a migraine attack. Overall, this study did not re-
port any added ecacy of BoNT/A for the prophylactic treatment of mi-
graine beyond placebo; however, subsequently, it was questioned whether
the dose (16 U) was too low. Finally, a third RBCT study looked at a subset
of 228 patients on the use of BoNT/A or placebo for the prophylaxis of
CDH, presumed to be of migrainous origin, without the confounding factor
of concurrent prophylactic medications [40]. The subjects were adults with
16 or more headache days per 30-day period; all had a history of migraine
or probable migraine and were not receiving concomitant prophylactic
headache medications. One hundred and seventeen subjects received
BoNT/A and 111 subjects received placebo injections. The maximum
change in the mean frequency of headaches per 30 days was 7.8 with
BoNT/A compared with only 4.5 with placebo. This dierence was statis-
tically signicant; the investigators concluded that BoNT/A was an eective
and well-tolerated prophylactic treatment for migraine headaches in patients
who had CDHs are were not using other prophylactic medications.
Chronic tension-type headache

In contrast to the open-label studies, in which some benet was shown
[41,42], the RBCTs that examined the use of BoNT/A for patients who
have CTTH or CDH suggest little to no benet. Specically in 2001, an

RBCT that involved 60 subjects concluded in the important outcome vari-
ables, such as pain intensity, number of pain free days and consumption of
analgesics, there were no statistical dierences between the [BoNT/A] and
control group [43]. In 2004, another RBCT on BoNT/A was performed
that involved 40 subjects who had CTTH [44]. The investigators concluded
that there was no signicant dierence between the two treatment groups
(BoNT/A or saline) on the patients assessment of improvement after 12
weeks. Finally, a large, multiple-center RBCT was performed [45]. This study
examined 112 patients who had CTTH using BoNT/A or placebo injections;
there were no signicant dierences between the two groups. Again, these
investigators concluded that there is no evidence of improvement with the
use of botulinum toxin A on CTTH. In 2006, two additional RBCTs reported
that for the primary endpoint, the mean change from baseline in the number
of TTH-free days per month, there was no statistically signicant dierence
between placebo and four BoNTA groups [46], and the between-group
dierence of 1.5 headache-free days favored BoNT-A treatment, although
the dierence between the groups was not statistically signicant [47]. Based
on these ve RBCTs that examined the use of BoNT/A in CTTH, the authors
conclude that the evidence for ecacy of BoNT in CTTHs and CDHs is non-
existent or weak at best.
Focal chronic orodental neuropathic pain

Based on the animal studies and pharmacology of the drug, BoNT/A
may well be eective as a treatment for focal trigeminal neuropathic pain
(eg, atypical toothache, phantom tooth pain, and possibly neuromas) that
is caused by nerve injury. Although not proof that oral neuropathic pain
will respond, one study examined localized postamputation pain before
and after BoNT injections [48]. This open-label case report described four
cases of chronic phantom pain of more than 3 years that were treated suc-
cessfully. The investigators used BoNT/A injected into four muscle trigger
points in the amputation stump of each patient. All trigger points were pain-
ful to compression before injection, and all patients reported referred sensa-
tions in the phantom foot from at least one of the trigger sites. In all cases,
the phantom pain was reduced by about 60% to 80%. In the absence of re-
ports of BoNT that is used to treat atypical odontalgia, phantom tooth pain,
or trigeminal neuroma pain, it is impossible to formulate an opinion on
whether BoNT/A will be helpful in treating these problems.
Trigeminal neuralgia
Several investigators have described the eects of botulinum toxin injec-
tions on trigeminal neuralgia. Unfortunately, all of these studies have been
258 CLARK et al
open-label, uncontrolled reports. The rst was a report on 11 patients who

had chronic facial pain that was due to trigeminal neuralgia. The investiga-
tors reported that 75% (8 of 11) of patients responded favorably, and
claimed that the benecial eect lasted between 2 and 4 months. In this
open-label study, BoNT/A was used at doses that ranged from 25 to 75 U
per patient [49]. Three additional case reports followed this initial report.
The sample sizes for these three studies ranged from a single patient to 13
patients. All of these reports described substantial pain reduction as a result
of BoNT injections, the dose ranged between 10 U and 100 U, and the im-
provement lasted between 2 and 6 months [5052]. Although these case
reports are interesting, they do not provide enough quality data to make
any recommendation about the ecacy of BoNT injections for trigeminal
neuralgia.
Trigeminal autonomic cephalalgia

Trigeminal autonomic cephalalgias include cluster headache, shortlasting
unilateral neuralgiform headache attacks with conjunctival injection and
tearing (SUNCT), and chronic paroxysmal hemicrania. These painful,
highly disruptive pain disorders are not prevalent enough in most clinics
for a randomized, blinded, clinical trial to be conducted to assess the eect
of botulinum toxin. For this reason, no RBCTs can be used to guide us
about the ecacy of BoNT for suppressing trigeminal autonomic cephalal-
gia pain events.
Summary
The animal experimental literature suggests that BoNT can inhibit pe-
ripheral pain processes, but BoNT cannot produce remarkable cutaneous
anesthesia in the area above an injection site. Although anesthesia is not
critical to blocking chronic pain phenomena if it were present, this would
strengthen the theory that BoNT might decrease neural input to the trigem-
inal nuclei, and, thus, potentially reverse chronic neuropathic pains that are
manifested in the head, neck, and orofacial regions. When the quality data
on this application are analyzed with regard to its use on patients who have
orofacial pain, the following conclusion are suggested:
The studies for resistant myofascial trigger points demonstrate no dier-
ence from already accepted lidocaine injections or even placebo
injections.
For temporomandibular pain and dysfunction, the published data are
awed in that a heterogeneous population has been used, and the
methodology and number of patients tested also can be called into
question. Insucient evidence is available to make specic treatment
recommendations.
For migraine prophylaxis, there is a general consensus among clinicians

who treat migraine that BoNTs may have an eective role in the pop-
ulation that has failed other modalities. It is the opinion of the authors
that the most evidence exists for migraine prophylaxis, and that in the
more refractory cases, BoNT is a viable treatment modality.
For CTTHs, the evidence does not support the use of BoNT injections.
For the trigeminal neuropathic conditions (eg, atypical facial and odon-
togenic pain and phantom tooth pain, and neuromas), acceptable evi-
dence is lacking.
For the use of BoNT in trigeminal neuralgia, the literature is limited to
case reports; few individuals have been treated. BoNT has not been
tested in a placebo-controlled, double-blind fashion in trigeminal neu-
ralgia; therefore, it is the opinion of the authors that insucient evi-
dence exists to be able to come to a denitive recommendation for
the use of BoNT for trigeminal neuralgia.
For the autonomic cephalalgias (eg, cluster headache, chronic paroxys-
mal hemicrania, and SUNCT), the literature is not sucient; therefore,
the authors are unable to come to a denitive recommendation.
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Dent Clin N Am 51 (2007) 263274
Complementary and Alternative

Medicine for Persistent Facial Pain
Cynthia D. Myers, PhD, LMTa,b,*
a
Integrative Medicine Program, H. Lee Mott Cancer Center & Research Institute,
12902 Magnolia Drive, Tampa, FL 33612, USA
b
Department of Interdisciplinary Oncology, College of Medicine,
University of South Florida, Tampa, FL, USA
Complementary and alternative medicine (CAM) is described by the

National Institutes of Health (NIH) National Center for Complementary
and Alternative Medicine (NCCAM) as a group of unconventional medical
systems, practices, and products not presently considered part of the con-
ventional biomedical care provided by medical doctors and other conven-
tionally trained health professionals [1]. For most CAM therapies, there
are unanswered questions regarding safety, cost-eectiveness, ecacy, and
mechanisms of action. Facilitating the scientic evaluation of CAM is
a key objective of NCCAM.
NCCAM groups CAM therapies into the following ve categories: mind
body interventions, manipulative and body-based therapies, biologically
based therapies, energy therapies, and alternative medical systems. Mind
body interventions aim to increase the minds capacity to enhance bodily
function and reduce symptoms. Examples from this category include bio-
feedback, relaxation, meditation, hypnosis, and yoga and other movement
therapies involving a component of mental focus. Spiritual approaches,
such as prayer, are categorized as mindbody interventions. Additional
mindbody interventions once considered to be outside of conventional
medical or dental treatment have achieved integration into multidisciplinary
pain treatment and mainstream care on the basis of evidence for their safety
and improved treatment outcomes resulting from their inclusion in com-
bined treatments [2]. These include patient education, cognitive-behavioral
* Integrative Medicine Program, MRC-PSY H. Lee Moffitt Cancer Center & Research
Institute, 12902 Magnolia Drive Tampa, FL 33612.
264 MYERS
coping skills training, and behavioral modication techniques such as habit

reversal.
NCCAM denes manipulative and body-based therapies as physical mo-
dalities such as massage therapy, chiropractic adjustments, and osteopathic
manipulations. Biologically based therapies include foods, vitamins, min-
erals, herbal products, and other natural substances used as dietary supple-
ments. Energy therapies are of two types. In the rst type, practitioners
intend to manipulate bioelds theorized to exist within and around the
patient. The second type of energy therapy involves the unconventional
use of electromagnetic elds for therapeutic purposes.
The nal category delineated by NCCAM, the alternative medical systems,
is comprised of complete systems of theory and practice, often predating
modern Western biomedicine. These systems share an aim to support an in-
nate tendency of the body toward health and can include interventions from
all the other categories of CAM. Homeopathy and naturopathy are examples
of alternative medical systems arising in Western culture. Homeopaths intend
to stimulate the bodys capacity for healing by providing minute doses of nat-
ural products. Naturopaths may use nutritional modications, dietary sup-
plements, homeopathic remedies, hydrotherapy, massage, and counseling
to prevent illness or to rebuild health. Traditional Chinese medicine uses
mindbody therapies such as tai chi and chi gong, which are meditative move-
ment therapies, along with natural products derived from plant and animal
sources, therapeutic massage, and acupuncture to facilitate and balance
energy ow, which is theorized to be central to health.
According to a comprehensive report produced in 2005 by the Institute of
Medicine on CAM and what is known about Americans use of it, CAM is
being integrated into conventional health care practice in hospitals and phy-
sicians oces, some health maintenance organizations are covering selected
CAM therapies, and insurance coverage for CAM is increasing. The Insti-
tute of Medicine recommended that health care should strive to be compre-
hensive and evidence based, with conventional medical treatments and
CAM held to the same standards for demonstrating clinical eectiveness [3].
Data on the use of complementary and alternative medicine

The most reliable data on the use of CAM by the general public in
the United States come from a 2004 report [4] based on the results of the
2002 National Health Interview Survey (NHIS). The NHIS, one of the
major data collection systems of the National Center for Health Statistics
of the Centers for Disease Control and Prevention, surveys nationally rep-
resentative samples of civilian households in the United States. The 2002
NHIS included questions on the use of CAM and was administered by in-
home, in-person interviews with 31,044 adults aged 18 and over, represent-
ing a response rate of 74%. Respondents were asked about their use (ever
and during the past 12 months) of 27 dierent CAM therapies, including
MEDICINE FOR PERSISTENT FACIAL PAIN 265
10 provider-based therapies (eg, acupuncture, chiropractic, and massage

therapy) and 17 CAM therapies for which a provider is not necessary (eg,
natural products, special diets, megavitamin therapy, and prayer for ones
own health). For therapies used during the past 12 months, respondents
were queried about the health problem or condition being treated with
CAM therapy and the reason or reasons for choosing CAM.
NHIH 2002 results indicated that 36% of United States adults used some
form of CAM during the prior 12 months when analyses did not include
prayer for health. Musculoskeletal conditions, including back pain or
back problems, neck pain or neck problems, and joint pain or stiness,
were the conditions for which CAM was most often used, conrming prior
studies nding chronic or recurring musculoskeletal pain linked to CAM use
[59]. More than a quarter of those using CAM believed that conventional
medicine would not help their health care problem. Consistent with earlier
surveys on CAM use [5,6], the 2002 NHIS found that most CAM users
also see medical doctors for conventional medical care. In addition to
pain, predictors of increased CAM use included higher educational attain-
ment, having private health insurance, living in an urban rather than rural
area, having been a smoker in the past but not currently, and female gender.
Given these national data on the use of CAM by the Unites States pop-
ulation, it would seem by an extension of logic that there might be relatively
high use of CAM by patients who have persistent facial pain because pain
and female gender are predictors of CAM use, and women are at higher
risk for persistent facial pain. Three published studies provide information
on CAM use by clinic samples of patients who have facial pain.
Turp [10] studied prior health care use by 206 consecutive patients re-
ferred to a tertiary care facial pain clinic and found that most patients
had previously consulted between one and four health care providers. Sev-
eral patients had seen more than four. Chiropractors had been consulted by
nearly 15% of patients, acupuncturists by 4%, and massage therapists by
2%.
Raphael and colleagues [11] indicated 22% of a sample of 63 women
meeting Research Diagnostic Criteria for temporomandibular disorder
(TMD) [12] but never previously treated with intraoral appliance used one
or more CAM therapy for their facial pain. The following treatment modal-
ities were classied by the investigators as CAM: acupuncture, relaxation
therapy, stress management, chiropractic, transcutaneous electrical nerve
stimulator, and biofeedback. Patients reporting greater interference in social
functioning due to pain had used more CAM. Patients for whom an acci-
dent was the initiating event for facial pain were seven times more likely
to have used CAM. Although the investigators did not raise this possibility,
it may be that access to CAM therapies was aected by the onset of facial
pain being linked to an accident because CAM therapies are sometimes
more readily covered by insurance when provided for injuries sustained in
an accident and are otherwise usually paid for out of pocket. Pain severity,
266 MYERS
pain duration, and mood did not predict CAM use. The investigators noted
that the fact that the women in their sample had not previously received an
intraoral splint suggested that their sample may have received fewer health
care interventions than many facial pain patients seen in tertiary care cen-
ters, and therefore estimates of CAM use from this sample might underes-
timate CAM use by patients who have more extensive treatment histories.
DeBar and colleagues [13] surveyed 192 patients (91% female) with docu-
mented TMD meeting Research Diagnostic Criteria about CAM use. Par-
ticipants had been part of pilot-phase focus groups or baseline assessment
for clinical trials on CAM for facial pain. More than one third of the sample
(35.9%) had used CAM for TMD, and nearly two thirds of the sample
(64.1%) had used CAM for other health conditions, with more than half
of these using CAM for another musculoskeletal condition (eg, back,
neck, or shoulder problems). Of the 69 participants using CAM specically
for TMD, massage was the most commonly reported CAM therapy
(66.7%). Chiropractic care (30.4%), biofeedback or visual imagery
(39.1%), and over-the-counter herbal supplements (21.7%) were also used
for TMD. Massage was reported as the most satisfactory CAM therapy
for TMD, and naturopathic care, massage, and chiropractic care were
most often rated very helpful for TMD. Herbal supplements and homeo-
pathic remedies were rated among the least satisfactory and least helpful
modalities used to treat TMD.
Among the most frequent reasons for using CAM for TMD in the study
by DeBar and colleagues [13] was a perceived failure of conventional treat-
ment to relieve symptoms (44.9%). Participants using CAM for TMD
tended to be older, were more likely to have a history of multiple medical
problems, and reported more positive psychologic functioning relative to
other participants. Noting the relatively high proportion of participants in
their study using CAM, the investigators suggested that it might reect
a self-selection bias because all participants were willing to take part in re-
search on CAM. Nonetheless, the investigators noted, their list of CAM
therapies was relatively narrow compared with other studies reporting lower
prevalence of CAM use with more inclusive denitions of CAM, and they
concluded that it is important to include systematic assessment of CAM
use when providing allopathic treatment of TMD.
Scientic evaluation of complementary and alternative medicine

for persistent facial pain
Published reports
To ascertain the most rigorous evaluation of completed research on
CAM therapies for persistent facial pain, published peer-reviewed clinical
trials randomizing patients who had facial pain to a CAM intervention or
to a control or comparison group and comparing outcome on at least one
patient self-report measure of facial pain were sought in the medical litera-
ture using the PUBMED and CINAHL electronic databases. The strategy
involved pairing the word pain with facial, TMJ, TMD, and temporoman-
dibular and with terms drawn from the literature on CAM therapies used by
facial pain patients: complementary, alternative, acupuncture, biofeedback,
relaxation, herbal, massage, chiropractic, homeopathic, and naturopathic.
Review articles were also sought in the same databases and in the Cochrane
Library. Studies were excluded if a CAM modality was administered in
combination with one or more other interventions (eg, relaxation training
or biofeedback as a component of cognitive behavioral stress management
training). Case studies were not sought.
Results
The present search strategy yielded 15 original research reports. Of these
15, eight tested biofeedback, three tested relaxation, and ve tested acupunc-
ture. (One tested biofeedback against relaxation.) Therefore, in terms of rep-
resentation of the NCCAM classications of CAM, interventions from the
mindbody interventions (biofeedback, relaxation) and alternative medical
systems (acupuncture) have been studied in controlled research available
through the current search strategy. No published results of randomized
controlled or comparison clinical trials were located testing the eects of
manipulative or body-based therapies such as chiropractic, massage, or
osteopathic manipulations, biologically based therapies such as dietary sup-
plements or herbal remedies, or energy therapies.
Biofeedback
In a review of electromyographic (EMG) biofeedback treatment alone or
in combination with stress management training for treatment of TMD,
Crider and Glaros [14] identied six trials with either a no-treatment or pla-
cebo control. Of the six no-treatment or placebo controlled trials, three
[1517] assessed the eects of EMG biofeedback alone on patient report
of pain. Hijzen and colleagues [15] found biofeedback to be associated
with signicantly greater reduction in myofascial pain dysfunction (MPD)
pain relative to intraoral splint or no-treatment control. Dohrmann and
Laskin [16] reported reduced pain and reduced masseter EMG levels in
MPD patients who were provided instruction in EMG biofeedback (n
16) as compared with placebo (n 8). Dalen and colleagues [17] reported
signicant reduction at follow-up in MPD pain intensity and pain duration
after participation in eight biweekly EMG sessions (n 10) or the control
condition (n 9). Findings from the three placebo or no-treatment control
trials therefore indicated that biofeedback training was associated with re-
duced pain, relative to control.
Five comparative trials were located [1822], three of which [1820] were
previously summarized in Crider and Glaros [14]. Olson and Malow [18]
268 MYERS
randomly assigned MPD patients to masseter biofeedback (n 6), frontalis

biofeedback (n 6), or frontalis biofeedback plus psychotherapy (n 6).
Relative to normative data from their patient population, the investigators
reported that the three treatments were associated with reduced pain report
and reduced tenderness upon examination. Frontalis biofeedback plus psy-
chotherapy was associated with the greatest reduction in tenderness. In
a sample of 30 patients, Dahlstrom and Carlsson [19] found self-report of
pain to be signicantly reduced at 1 month and 12 months post-treatment
with EMG biofeedback training or intraoral splint, with no signicant dif-
ference between treatments. Mishra and colleagues [21] compared biofeed-
back training (EMG and thermal), cognitive-behavioral skills training
(CBST), combination biofeedback/CBST, and no-treatment control in 94
patients who had TMD who were randomly assigned to treatment. The bio-
feedback-only group showed the greatest improvement post-treatment, but
participants in all three active treatments reported pain reduction relative to
pretreatment. Combined biofeedback/CBST treatment was associated with
the most improvement at 1-year follow-up. Erlandson and Poppen [22] ran-
domized female MPD patients to three groups: Group 1 received instruction
in bilateral masseter EMG biofeedback, Group 2 received bilateral masseter
EMG biofeedback plus instructions on placing the jaw in a resting position,
and Group 3 received bilateral masseter EMG biofeedback plus intraoral
prosthetic guides. Of the patients initially reporting pain, one in four pa-
tients in Group 1 reported a decrease in pain, four of ve patients in Group
2 reported a decrease in pain, and three of four patients in Group 3 reported
reduced pain. Given the study design, it is dicult to make direct compar-
isons between groups; however, it seems that in this study EMG biofeed-
back was more eective in combined treatment than as a sole treatment.
Funch and Gale [20] reported no between-group dierence on outcomes
post-treatment in patients who had chronic temporomandibular joint pain
randomly assigned to biofeedback (n 30) or relaxation training (n 27).
To summarize the evidence from biofeedback studies, biofeedback was
consistently superior to placebo or no-treatment control in terms of pain
reduction in three trials. Results of comparison of biofeedback to other ac-
tive treatments yielded mixed results in pain outcomes, with biofeedback
alone sometimes superior to the comparison group, sometimes equivalent
to comparison, and sometimes less eective than the comparison group.
Participant samples were generally small in these biofeedback trials.
Relaxation
Three trials of relaxation training [20,23,24] met criteria for discussion.
Additional trials incorporating relaxation training were located but are
not reported here because pain was not assessed by self-report [25] or be-
cause relaxation training was provided as a component of multicomponent
training [26,27]. In a comparison trial, Funch and Gale [20] found no
dierence on post-treatment pain report between two active treatments:

relaxation training involving the use of audiotaped instructions for muscle
relaxation (n 27) and biofeedback (n 30). Winocur and colleagues
[23] evaluated the eectiveness of hypnorelaxation (n 15) compared
with occlusal appliance (n 15) or minimal treatment (n 10) for women
who had masticatory myofascial pain disorder. Results indicated that both
potentially active treatment groups were superior to minimal treatment with
regard to muscular sensitivity on palpation, but only hypnorelaxation was
signicantly more eective than minimal treatment with regard to patients
self-report of pain on a visual analog scale. Sherman and colleagues [24] ran-
domly assigned 21 patients with mixed facial pain diagnoses to a single
session of stretch-based relaxation or a session of resting and found no
signicant group dierences post-treatment on pain.
To summarize results of studies on relaxation, no placebo-controlled
studies were located. Three comparison trials were located. Relaxation
was equivalent to two potentially active treatments used as comparison
interventions (biofeedback or resting) and was superior to occlusal appli-
ance. As was the case with biofeedback trials, participant sample size was
relatively small in studies of relaxation eects on persistent facial pain.
Acupuncture
Five qualifying trials of acupuncture for persistent facial pain were
located [2835]. In two of these, acupuncture was compared with a no-
treatment control. Johansson and colleagues [28] randomly assigned 45
patients who had TMD to acupuncture, intraoral splint, or control. Pain
was assessed pretreatment and at 3 months follow-up in the two treatment
groups and at 2 months follow-up in the control group. Both active treat-
ments were associated with signicant improvement relative to control
post-treatment. A limitation of the study results from the use of diering
follow-up periods for the two treatment groups and the control group. List
and colleagues [29,30] randomly assigned 110 patients who had TMD to acu-
puncture, intraoral splint, or wait list control. Pain diaries were completed by
96 patients, with results indicating that both active treatments were associ-
ated with signicant pain reduction at post-treatment and follow-up.
Three studies compared acupuncture with another active treatment or to
sham treatment. Raustia [3133] randomly assigned 50 patients who had
TMD to acupuncture or to a multimodal treatment including counseling,
occlusal adjustment, splint therapy, and exercises. Immediate results slightly
favored multimodal treatment; however, the two treatment groups did not
dier at follow-up. Schmid-Schwap and colleagues [34] randomly assigned
female patients who had TMD to needle acupuncture (n 11) or sham laser
acupuncture (n 12). Needle acupuncture was associated with signicantly
greater reduction in self-reported pain immediately post-treatment; how-
ever, pain ratings were higher pretreatment in the acupuncture group.
270 MYERS
Thus, regression to the mean cannot be ruled out. Goddard and colleagues
[35] randomized 18 patients who had facial pain (15 females) to acupuncture
at authentic (n 10) versus sham (n 8) acupuncture points. In this study,
patients did not rate their clinical pain; rather, patients used visual analog
scales to rate pain evoked by the maximal pressure they could tolerate
from a pressure algometer applied to the masseter muscle 5 minutes before
treatment and again post-treatment. Both groups showed signicant reduc-
tion in their ratings of the post-treatment pressure stimulus, with no signif-
icant between-group dierence, indicating that the eects on pain were not
dependent upon location of needle insertion.
To summarize results of studies of acupuncture for persistent facial pain,
two studies used three-group designs that permitted testing acupuncture
against a control condition and comparison to an active treatment. Both
studies found acupuncture to be superior to control but equivalent to the
comparison treatment in terms of pain outcomes. Two studies compared
acupuncture with a comparison or sham treatment and showed mixed
results in terms of eects on patients self-reported clinical pain. In one
study [3133], acupuncture was less eective than an active treatment com-
parison immediately post-treatment but was no dierent at follow-up. One
study found acupuncture to be superior to sham treatment [34]. One study
in patients who had facial pain using evoked facial pain rather than persis-
tent clinical facial pain as its outcome found acupuncture to be equivalent to
sham acupuncture in reduction of evoked pain. Three trials [2833] were
previously described in two published systematic reviews [36,37].
Emerging data
Two relatively large-scale, NIH-funded, randomized clinical trials have
recently been completed investigating the eectiveness of CAM modalities
for treatment of TMD meeting Research Diagnostic Criteria. As of this
writing, results of the two studies have been submitted for publication
and are under peer review. In personal communication, Nancy Vuckovic,
PhD, Principal Investigator of the studies at the time of their completion,
provided a description of the studies, which were supported by NCCAM
through a center grant to the Oregon Center for Complementary and Alter-
native Medicine in Craniofacial Disorders, headquartered at the Kaiser Per-
manente Center for Health Research in Portland.
In Study I, participants with newly diagnosed TMD were randomized to
one of ve groups: (1) 10 sessions of a standardized acupuncture protocol
for patients; (2) 10 sessions of a protocol allowing acupuncture treatment
from a menu of acupuncture points and herbal treatment for patients
diagnosed with TMD by dental criteria and also evaluated according to tra-
ditional Chinese medicine diagnosis; (3) 10 sessions of a standardized full-
body massage protocol incorporating intra-oral massage; (4) 10 sessions
of chiropractic treatment using a set protocol including manipulation of
the full body with attention to the relationship of the pelvis to the jaw; and
(5) usual care at Kaiser Permanente, which could include accessing the
TMD Clinic, intraoral splints, pain medications, referral for physical
therapy, stress reduction, and self-care training. Primary outcomes were
pre- and post-treatment assessment of Research Diagnostic Criteria with
follow-up at 3, 6, 9, and 12 months post-treatment. Secondary outcomes in-
clude assessing treatment eects on depression and assessing the relationship
of social support and expectations of treatment at baseline to outcomes.
In Study II, women between 25 and 55 years of age who had TMD and
comorbid conditions (eg, chronic fatigue, bromyalgia, irritable bowel syn-
drome, or migraine) were randomized to one of three groups: (1) 20 sessions
of traditional Chinese medicine, including acupuncture, for a total of 10.5
hours of contact over a 6-month period; (2) 10.5 hours of naturopathic
care over a 9-month period; or (3) usual care the same as in Study I. This
study aimed to examine a more whole-systems approach, with diagnosis
and treatment undertaken within the sphere of the CAM discipline (ie, tra-
ditional Chinese medicine diagnosis, naturopathy diagnosis). Outcomes are
dental outcomes related to the Research Diagnostic Criteria and the other
outcomes used in Study I.
Results of these two studies, regardless of the ndings, will help to move
research forward in the eld of CAM for persistent facial pain. Protocols
were developed by experienced clinical researchers in collaboration with
dental experts and experts in the CAM therapies studied, yielding an exem-
plary interdisciplinary eort. The study designs will help to provide valuable
information about the results of these treatments used in a manner similar to
how they are used clinically, with several visits over time. CAM therapies
tend to be administered in the community in a highly individualized fashion,
which renders them challenging to replicate in research. The protocols tested
by the Oregon Center for Complementary and Alternative Medicine in Cra-
niofacial Disorders studies, although not testing completely individualized
approaches, allowed some exibility in select treatment arms and may there-
fore begin to answer questions about dierences between standardized ver-
sus individualized protocols for CAM treatment of facial pain. According to
Dr. Vukovic, there were no adverse events resulting from the studies, with
the exception of minor bruising at the point of acupuncture needle insertion,
which is not unexpected.
Summary
Population-based national data suggest that greater than one third of the
general adult population in the United States uses CAM. Although CAM is
used for a variety of indications, musculoskeletal pain is the leading reason
for CAM use. Preliminary studies of clinical samples on the use of CAM by
patients who have persistent facial pain indicate that these patients use
CAM therapies, including manipulative and body-based therapies, such as
272 MYERS
massage therapy and chiropractic manipulation; mindbody interventions,

such as relaxation and biofeedback; biologically based therapies, such as
herbal supplements; and alternative medical systems, such as homeopathy,
naturopathy, and traditional Chinese medicine, in a eort to manage pain
and improve health.
Initial scientic evaluation has been done on biofeedback and relaxation
and on one aspect of traditional Chinese medicine (ie, acupuncture). These
preliminary studies indicate superiority of the three CAM treatments rela-
tive to placebo or control and generally comparable results to other conser-
vative treatments for persistent facial pain. Other CAM therapies in use by
facial pain patients remain virtually unknown from the standpoint of con-
trolled or comparison studies. There is a great deal of research to be done
to thoroughly evaluate the safety, ecacy, and mechanisms of complemen-
tary therapies for persistent facial pain. For example, herbal and dietary
supplements have become widely available and popular, and facial pain pa-
tients report their use. However, some of these products possess antiplatelet
activity, hepatotoxicity, adverse interactions with central nervous system de-
pressant drugs, and additive eects when used with opioid analgesics [38].
Fortunately, support for research on CAM has increased in recent years.
To illustrate, results of two relatively large-scale, NIH-funded studies on
CAM for persistent facial pain will soon be known.
We must rise to the challenge of evaluating CAM therapies so that we can
best guide patients seeking relief from vexing pain, which does not always
fully resolve with the approaches we use and teach in dental medicine.
Additionally, we must be informed about potentially harmful CAM thera-
pies so that we can advise patients based on unbiased evidence to help
them to make informed health care decisions. In this way, we work together
to best serve our patients by creating health care that is comprehensive and
based upon scientic evidence of clinical eectiveness.
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Dent Clin N Am 51 (2007) xixii

Henry A. Gremillion, DDS

Since the last issue on temporomandibular (TMD) disorders and orofa-

As guest editor, I wanted to provide a forum in which the many facets of

Henry A. Gremillion, DDS

Overview of Orofacial Pain: Epidemiology and Gender

Peripheral Mechanisms of Odontogenic Pain 19

Central Mechanisms of Orofacial Pain 45

VOLUME 51 NUMBER 1 JANUARY 2007 v

Joint Intracapsular Disorders: Diagnostic and Nonsurgical

Temporomandibular Disorders: Associated Features 105

Temporomandibular Disorders and Headache 129

Psychological Factors Associated with Orofacial Pains 145

Temporomandibular Disorders, Head and Orofacial Pain:

Temporomandibular Joint Surgery for Internal

Neuropathic Orofacial Pain: Proposed Mechanisms,

Four Oral Motor Disorders: Bruxism, Dystonia,

A Critical Review of the Use of Botulinum Toxin

Complementary and Alternative Medicine for Persistent

Overview of Orofacial Pain:

Epidemiology of orofacial pain

* Corresponding author. Department of Community Dentistry and Behavioral Science,

patterns and presenting symptoms, and a lack of consensus regarding dier-

Sex dierences in responses to experimental pain

Nonhuman animal research

and direction of sex dierences [24,28,36]. A meta-analysis conducted by

aspartate [NMDA] glutamate receptors [50,51]. Temporal summation is

Brain imaging studies

stimulus, which was rated as more painful by women, whereas Derbyshire

Sex dierences in analgesic systems

electrical stimulation of the lower extremity) activity in women and men,

however, the melanocortin-1-receptor genotype (MC1R) was associated

Clinical relevance of experimental pain responses

sex dierences in experimental pain sensitivity are related to sex dierences

Responses to nonpharmacologic treatment

Mechanisms underlying sex dierences in pain perception

In addition to emotional factors, cognitive variables, such as self-ecacy,

Summary and future directions

[134] Rajala U, Keinanen-Kiukaanniemi S, Uusimaki A, et al. Musculoskeletal pains and depres-

knowledge regarding pain mechanisms when designing experiments, and cli-

whose role involves vasoconstriction [13], whereas parasympathetic bers

especially implicated in inammatory processes because sensory nerve stim-

Mechanisms for detecting stimuli and clinical implications

receptors. In general, activating a Gai signaling pathway leads to the inhibi-

Voltage-gated ion channels

PERIPHERAL MECHANISMS OF ODONTOGENIC PAIN

Sodium channels: the Navs

compared with normal tooth pulp [116,117]. One possible consequence of an

Potassium channels: the voltage-gated potassium channels and others

medications, including opioids. This occurs indirectly because opioid bind-

Calcium channels: the voltage-gated Ca2 channels and a few others

the neurotransmission of nociceptive stimuli. The analgesic action of various

The transient receptor potential channels

expression of this ligand-gated channel is critical for the development of

The future: toward a molecular model of pain diagnosis and management

dierences in patterns of aerent input as pivotal in pain perception, con-

[102] Gaida W, Klinder K, Arndt K, et al. Ambroxol, a Nav1.8-preferring Na() channel

Central Mechanisms of Orofacial Pain

A review of the literature for temporomandibular disorders (TMD) has