Similar to TMJ pain, orofacial pain encompasses a variety of diagnosis but most often is reported as generalized pain in the face. Dysfunction of the temporomandibular joint and the muscles of mastication can produce symptoms both locally and along documented referral patterns in the facial region. Additionally, degeneration of the cervical spine and strains of the surrounding musculature can produce referred pain in the jaw, face and head. These occasionally vague symptoms can make it difficult for some other specialties to diagnose, however TMD physical therapists recognize the cause by addressing structures in both the neck and head. Throughout therapy, the activities and distribution patterns of the trigeminal nerve (CN V) are considered, as motor and sensory functions may be affected.
The Basis of TMD Rehabilitation
Resolving orofacial pain is often found in the cessation of parafunction; nail biting, excessive gum chewing and snacking on hard foods. These activities can irritate the TMJ, facial muscles and nerves, and result in orofacial pain. Instruction on the proper position of the jaw, teeth and tongue are essential components in both the immediate reduction of symptoms and lessen the possibility of recurrence. Additionally, poor posture can directly produce stress on the jaw. Although it is most often observed with the use of electronics; workstation, sleep and driving postures uniformly contribute to orofacial pain.
Cessation of parafunction activities will greatly reduce the stress on the neck, jaw and facial structures. Posture is also an essential component of orofacial pain and is consistently emphasized throughout physical therapy treatment. Slight modifications to daily activities and a conscious awareness of the position of the jaw and neck produce long term pain relief. Orofacial pain is the result of nerve and muscle inflammation, therefore reducing the daily stress on these structures will reduce overall pain in the head and face.
Decreasing Acute TMD Inflammation
The immediate goal in physical therapy treatment of orofacial pain is the reduction of acute symptoms. Most patients report moderate to severe pain which effects daily activities. The use of moist heat, electrical stimulation and cold laser provides a localized increase in blood flow and a reduction of pain. While these interventions are not the permanent solution to orofacial pain, the resulting reduced symptoms prepare the area for more advance interventions.
Additionally, iontophoresis is another modality which may be utilized to reduce inflammation on the cellular level. This process involves the application of a pain-free current to the jaw region, which applies a prescribed steroid trans-dermally (through the skin). This is administered during physical therapy treatments and in conjunction with your dental professional. It is often recommended when the jaw regions are severely tender to palpation or when a patient has been unresponsive to other interventions. This intervention can also reduce inflammation in the trigeminal nerve distribution.
Remodeling Soft Tissue
A comprehensive assessment and manual treatment of the muscles and skeletal structures of the orofacial region is essential with orofacial pain. A skilled TMD physical therapist is often the first healthcare provider who assesses and addresses the soft tissue in the TMJ regions. This includes the muscles of mastication, which are responsible for both opening/closing the mouth and chewing. Research has consistently shown that trigger points in these muscles can result in tooth pain, headache and facial pain. Furthermore, the cervical structures are often overlooked when determining orofacial pain. Similarly, contemporary research confirms the directly relationship of muscles in the neck and orofacial pain.
Manual therapy initially helps to desensitize highly irritated facial areas, typically within the trigeminal nerve innervation patterns. Skilled TMD physical therapist address the muscles and soft tissue structures of the neck and jaw to reduce orofacial pain. Utilizing soft tissue mobilization and myofascial release techniques, muscle adhesions are reduced and normal movement patterns return. The neck and jaw muscles are comprehensively manipulated both superficially and intraorally. The temporomandibular joint is also mobilized to stretch the joint capsule and surrounding ligaments, which often tighten with the onset of pain. Cranial distraction and stretching of the cervical paraspinals is often utilized to reduce compression and tightness.
An Advanced Treatment
In some cases, the resolution of muscle knots and myofascial adhesions require more aggressive treatment. Dry needling is a minimally invasive procedure in which a solid filament needle is inserted into the muscle directly at a persistent trigger point. While the needle used is similar to acupuncture needle, the technique and methodology varies greatly. The sole purpose of dry needling aims to decrease contraction knots, which are related to the production and maintenance of the pain cycle. These very thin needles and inserted through the skin and can affect deep layers of muscle tissue. Dry needling in the orofacial region also allows TMD physical therapists to address muscles unreachable by the fingers.