Head and Neck Pain

It is our hope at PPM Journal that this brief, but important tutorial will help to provide a “bridge” of critical information for the pain management disciplines. The “bridge” conveys foundational information about the TMJ. Some TMJ cases exhibit diffuse, aching pain and pressure while others exhibit ear pain, or neuralgic pains mimicking Trigeminal neuralgia. TMJ-related ear pains cause the patient to be seen by an ENT, whereas the neuralgic symptoms often cause the patient to be directed to a Neurologist or a Neurosurgeon, who may find themselves limited in making a correct diagnosis. The addition of the TMJ exam screen, if not currently being done, may make the difference for the patient and avoid potentially tragic decisions as outlined in a case illustration that follows at the end of the tutorial.
—Edwin A. Ernest, III, DMD

Pain of the temporomandibular joint or TMJ is a common finding among patients who suffer headache, earache, and head and neck pain. Several studies done at Medical Center-based ENT services have documented that approximately fifty-percent of walk-in patients seeking help for ear pain have a TMJ disorder that is the source of pain referred to the ear.¹ Thirty-seven percent of those patients have objective, measurable symptoms of hearing loss related to the TMJ disorder. Other patients have diffuse neuralgic pain of the face and head. Clearly, there is a demonstrated need for pain practitioners to be able to quickly screen the TMJ so that the patient is properly directed for care.

Misconceptions
Before we discuss the screening process, we need to review several misunderstandings about the TMJ. First is the belief that if the joint hurts then the joint needs TMJ surgery. The truth is TMJ surgery is not as frequently done today as it was in the 1980’s. Some, if not many, of the TMJ surgery cases done in the 1980’s were a result of poor case selection with little or no knowledge of pain conditions that can refer to the TMJ. In the 1990’s, surgeons were sensitized by the failures of the 1980’s. Some surgeons will no longer operate on the TMJ at all while others will only operate for case specific issues such as “joint mice,”or other conditions besides “pain,” that may offer a predictable chance for success. The end of the 1980’s and the decade of the 1990’s proved the TMJ area to be much more complex than previously understood.

Jaw joint pain is not always an expression of a slipped articular disc or a systemic disease process such as psoriatic arthritis. What many do not recognize is that oftentimes pain is referred to the joint. A few examples of this are Hyoid Bone Syndrome, Temporal Tendonitis, Ernest Syndrome, tumors, Omohyoid Muscle Syndrome, C2-3 cervical facet, cervical nerve root, as well as other conditions where pain is referred to a number of sites, including the TMJ.^2-4 If these types of referred pain cases are mistakenly perceived as a TMJ joint problem, surgical intervention usually ends in failure because the diagnostic complexity goes unrecognized.

Please refer to the April 2007 issue for the complete text. In the event you need to order a back issue, please click here.