Treating Myofacial and Other Idiopathic Head and Neck Pain
There are a number of different issues that come to rise in both the physician’s office and the dental practice. One that has surfaced is the prevalence and subsequent treatment of head and neck pain. The problem is that, for people who suffer with such pain, there has been little that can be done to help remedy the problem and patients go through a fairly typical pathway ultimately feeling that there is little to no hope. Throughout time, headaches have plagued people and various solutions have been tried and abandoned. Despite advances in modern healthcare, real answers still do not exist for a number of problems our patients deal with.
It would not be appropriate to claim a panacea for multi-factorial issues or to promote a singular approach of treating every collection of symptoms that hints at head and neck pain, however there are some incredibly interesting developments in the field of dentistry that would be of major benefit to the primary care physicians and those who deal with issues of pain in the head and neck. It is analogous to the story of several blind people who each described an elephant. Since none could see the whole elephant, their impression of what an elephant looks like was totally dependent on the picture in their mind’s eye based on what they feel. The man feeling the tail, the one feeling the leg, the one feeling the belly, and the one feeling the trunk will see, in their mind’s eye, a very different animal. And so it is with pain in the head and neck.
This would not be an issue if patients were not still dealing with pain, however the incidence of migraine in the United States is just a little over 10% and the incidence of headache is over 15%. Together that is more than one in four people who are dealing with significant pain and discomfort. As the pain of those patients becomes severe enough that they seek help, they go to the only logical provider—their physician. In many cases, there is some benefit in following advice, managing allergies, controlling food intake or supporting the patient with medication. The interesting thing that has come to light recently is the benefit of support from a dentist who understands and employs physiologic support of comfortable muscles. As a physician treating chronic pain in the head and neck, it is unlikely that the concepts of neuromuscular dentistry will fall into the realm of training. Unfortunately, even most dentists have not been exposed to the neuromuscular approach. Nevertheless, there are a number of dentists around the world who are employing these concepts in the evaluation of their patients and are experiencing excellent results. With this track record of success, it is time to share the benefits of our various perspectives so that we can accurately describe the complete picture and finally get these patients some help.
From the early days, dentists have looked for better ways, including initial skull studies, to be able to provide prosthetic teeth that are comfortable. In order to better support a patient’s dentures, about a hundred years ago dentists started grinding dentures flat so that they hit on both sides at all the time. While this helped to keep dentures seated, it did not actually restore proper functional dynamics. When these concepts were applied to the natural teeth of dentate patients, they led to an opportunity to improve the understanding of the mouth.
In the 1930s and 1940s, the concepts developed were more focused on the importance of the bumps on the teeth. Gnathology was the study of the effect and relationships between the various bumps on the teeth and these concepts would not only enable the prosthetic teeth to function more efficiently, they would also fit better in natural dentition. However, there were still issues with macro-occlusion—the relationship not between the teeth but between the upper and lower jaw. As these issues came to light, the profession was again afforded the opportunity to increase awareness and understanding.
About a generation later, the improved understanding had grown into the widely accepted theories of centric relation-based occlusion. Within this perspective of the ideal function of the jaws, the basic concepts of balanced contacts between teeth were improved and the importance of the bumps and grooves in the teeth was supported. The major benefit is that it allowed for the perspective of macro-occlusion. What this theory purports is that there is a particular relationship between the position of the condyle and the glenoid fossa and, once the jaw is place in and supported in that position, the mouth will function correctly. Unfortunately the theory was lacking because it was based on a skeletal or bone-braced position and the notion that there is a rotation of the lower jaw in, or around, the temporomandibular joints. Considering the condyle or head of the mandible will distort in a pathologic position—as well as the fact that there simply is never a pure rotation around or even close to the joints—this theory falls a bit short of describing proper function of the jaw.
In the early 1970s, a dentist and physician worked together to help to understand the complicated and multifaceted jaw joint and all the implications it brings to our treatment protocols. Based on work by researches such as Dr. Janet Travell and her enormously beneficial perspective of muscle function and physiology, a more complete picture started to develop. The concepts of neuromuscular dentistry began to come together and, through the efforts of Dr. Barney Jankelson, a new and broader understanding of dentistry emerged. The major benefit of this growth is that rather than looking for a static and mechanical relationship to control a very fluid and dynamic system, the key concepts and fundamental perspective is one of soft tissues first. Rather than just looking at the wearing down of teeth, or looking at boney references that are also subject to distortion and physiologic change, it is important to also consider the support muscles as a determinant of jaw health. The key to developing a physiologically-balanced system lies in understanding the physiology of the entire system.