©Devin Starlanyl, MD 1995-1998
You have seen patients with fibromyalgia (FMS) and myofascial pain syndrome (MPS), and will see more. They are very real medical conditions, often occurring together, and both are very different, although often confused. They may be the answer to some of your "challenging" patients. FMS is a systemic neurotransmitter condition with, among other things, a disrupted adrenal-hypothalamus-pituitary axis. It is nonprogressive (although it may seem so), nondegenerative, and noninflammatory. It is responsible for diffuse body-wide pain, tender points that hurt but don't refer pain, and sleep disturbances. Chronic MPS is a musculoskeletal chronic pain syndrome. It is nonprogressive (although it may seem so), nondegenerative and noninflammatory. It is composed of many trigger points (TrPs), which refer pain and other symptoms in very precise, specific patterns. It seems progressive because each TrP can develop satellite and secondary TrPs, which can form secondaries and satellites of their own. With treatment of the TrPs and underlying perpetuating factors, however, these TrPs can be "reversed" and minimized or eliminated. When occurring together, what I call the "FMS&MPS Complex" forms. This is a condition of interconnected symptom spirals that get increasingly worse until the spiral is interrupted. For example, the pain causes muscle contraction which causes more pain which causes more contraction, etc. The patient can sometimes have muscles that are like cement, due to myofascial splinting. One of the most vital things for you to know is that your patient can have various muscles constricted in such a way that the bite can be pulled off. When the TrPs are treated, the bite will change. This is a disaster if you have equilibrated the bite to the contraction of the muscles. TrPs can be caused by a poor bite, and the reverse is also true. Equilibration and TrP treatment must occur together. Otherwise they may both be ineffective. Two excellent medical texts are available on MPS, "Myofascial Pain and Dysfunction: The Trigger Point Manual Vol. I and II" by Janet G. Travell M.D. and David G Simons M.D. The first volume is important to you, as it deals with upper body TrPs. This information is but an introduction to TrPs. These texts show the referred patterns, tell what causes them, and how to relieve them. 30% of FMS&MPS Complex patients have TMJ. Suspect TrPs, especially if there's no disc problem, just dysfunction and pain. TrP pain is rarely symmetrical. Your patient usually presents with complaints due to the most recent activated TrP. When this is eliminated, the pain pattern may shift to an earlier one, which also must be inactivated. Trigger points are activated directly by acute overload, overwork fatigue, direct trauma, and by chilling.
TrPs are also activated indirectly by other TrPs, visceral disease, arthritic joints, and by emotional distress. Active TrPs vary from hour to hour and day to day. The signs and symptoms of TrP activity long outlast the precipitating event. When a nerve passes through a muscle between taut bands, or when a nerve lies between the taut band and bone, the unrelenting pressure exerted on the nerve can produce neuropraxia, loss of nerve conduction, but only in the region of compression. The patient has two types of pain symptoms -- aching pain referred from the TrPs in the muscle, and nerve compression effects of numbness and tingling hypoesthesia and sometimes hyperesthesia. Patients with nerve entrapment prefer cold on the painful region. Patients with myofascial pain prefer heat and say cold aggravates the pain.
Some common TrP perpetuating factors affecting the mouth area are skeletal asymmetry and disproportion. Also important are nutritional inadequacies, any condition impairing muscle metabolism, chronic infections, psychological factors, allergy, bad habits such as chronic gum chewing, and impaired sleep. Most common TrP perpetuating factors I've found are FMS and inappropriate treatment programs.
TrPs that refer burning, prickling or lightning-like jabs of pain are likely to be found in cutaneous scars. Scar TrP deactivation can often be accomplished by intracutaneous injection with 0.5% procaine or by repeated application of topical anesthetic, dimethisoquin HCl ointment (Quotane). TrPs may also be found in joint capsules and ligaments. Periosteal TrPs often produce autonomic reactions, such as sweating, blanching, and nausea, or by repeated application of topical anesthetic. TrP sites can vary slightly from patient to patient. Many muscles have multiple TrP locations. A lump at the TrP site could be due to damming of blood and other fluids by obstructed blood flow. The major factor in TrP pain is always mechanical, even if triggered by stress. Limitation of range of motion is worse in the morning, and may recur after periods of immobility(such as dental work) or over-activity during the day. The chronic stress of the resultant sustained contraction, or excessive fatigue during repeated contractions, may cause a vulnerable region of the muscle to become strained, repeating this same process.
Common TrPs Encountered by Dentists
Bruxism: Teeth clenching is the default mechanism of the brain. When it doesn't know what to do as a response to mixed or erratic signals, it clenches the jaw -- sort of a cerebral twiddling of the cranial thumbs. Check out the masseter TrPs and temporalis TrPs.
Unexplained toothaches: This confusing symptom can be caused by several TrPs, chiefly in the temporalis, digastric and masseter muscles. Each TrP has its own particular toothache pattern. A TrP-induced toothache is usually intermittent. During a long dental procedure, which often activates these TrPs, you should take periodic rests to exercise and relieve the jaw muscles. Anterior digastric refer pain to the two front lower teeth.
Motor coordination problems: The sternocleidomastoid is much of the problem here. SCM TrPs can cause dizziness, imbalance, neck soreness, swollen gland feeling, runny nose, maxillary sinus congestion, "tension" headaches, eye problems (tearing, "bug-eyes", blurred or double vision, inability to raise the upper lid, and a dimming of perceived light intensity), spatial disorientation, postural dizziness, vertigo, sudden falls while bending, staggering walk, impaired sleep, nerve impingement, and disturbed weight perception. It can cause secondary TrPs that invoke dental pain. People with SCM TrPs often have trouble glancing downward -- they can get so disoriented that there is nausea and vomiting. Chronic dry cough, pain deep in the ear canal, pain to the throat and back of the tongue and to a small round area at the tip of the chin can be part of the SCM TrP package. Localized sweating and vasoconstriction can be a problem, as well as pain in a "skull cap" area of the head. What SCM TrPs don't cause is a pain in the neck, although they figuratively become one due to their wide-ranging symptoms.
FMS&MPS Complex Nocturnal Sinus Syndrome: This is not an official name. I use it here because I have never seen it described. This is a nighttime sinus stuffiness on one side, that moves to whatever side of your head is lower. Gravity drains the congestion to the lower side. This condition goes along with post nasal drip and often a constantly runny nose. TrPs form which often refer teeth pain.
Runny nose: Almost all FMS&MPS Complex patients have this form of "vasomotor rhinitis". That's a runny nose with no "biological" cause. I think, and this is just my theory, that with muscle tightening, normal fluid passages are constricted, and fluid backs up in the sinuses. So we get a constant post nasal drip all night, although the membranes of the nose may feel very dry and even bleed. Bruxism, chewing gum, playing wind instrument or violin will often aggravate neck TrPs.
Problems swallowing, chewing pain, jaw clicking, TMJD, soreness inside the throat, excessive saliva secretion and sinusitis-like pain, drooling in sleep, choking on saliva -- can all come from an internal medial pterygoid TrP, which is often overlooked.
Prickling "electric" face pain over the jaw area: This pain is from the platysma TrP.
Popping or clicking of the jaw, TMJD (temporomandibular joint dysfunction): Jaw pain and dysfunction is often the fault of one or more masseter TrPs, although trapezius and temporalis TrPs are often involved. Itchy ears can also be caused by the masseter TrP. The itch, which can drive you to distraction, can often be relieved by acupressure on that TrP.
Tooth pain: Cutaneous facial TrPs can cause pain in the ear, eyes, nose and teeth. These TrPs are shallow, and can occur in many places on the face. Try acupressure. If the TrPs are there, they will let you know.
Headaches: The SCM is a common cause of headaches. So, indirectly, are any of the causes of sore throat, for often a sore throat refers pain to the head. The posterior cervical TrP is also suspect if it entraps the occipital nerve. This will cause a numbness, or a tingling, burning pain -- like a band around head. Many upper body TrPs can be involved in headaches. See the headache handout.
Patients with FMS&MPS Complex may react in unusual ways to bite splints. Sometimes splinting makes things worse for them. Patients have been known to bite right through a splint in one night.
For FMS&MPS Complex patients, even teeth cleaning can be severely painful, because FMS is a pain amplification syndrome. Studies indicate that some of our touch receptors have become pain receptors. Tense muscles from the pain of cleaning may cause the jaw to hurt for over a week. You might try numbing the bottom teeth where most of the scaling is necessary. Sometimes topical numbing is sufficient to eliminate most of the pain of cleaning.
It is also helpful if there are frequent stops to move the jaw during cleaning and other dental work. Some patients take a muscle relaxer, such as Skelaxin, before and after cleanings, to allow for more stretching of the jaw. FMS&MPS Complex patients can even experience pain during X-ray -- those squares cut in right in, especially under the tongue. Have the patient work on the masseter for the next few days, using moist heat and acupressure. Many FMS patients cannot tolerate with epinephrine in the local anesthetic.
Root canals can be torture. We feel pain earlier in the case of a threatened nerve. We feel extreme pain longer, often when other patients would feel none at all. Sometimes it is impossible to eliminate all of the pain. It is vitally important to get all the roots. Several people have reported cases of "myofascial neuralgia" after a root canal -- with pain that lasted a month or more. We have had a few members of the Internet group complain about teeth cracking after this procedure.
People with FMS&MPS Complex have more than the usual difficulty adjusting to dentures. It is important that dental problems are fixed promptly. Dentures must fit, and any imbalances in the bite must be corrected. TrPs on both sides should get treatment due to the interrelation of the musculature and jaw structures. For TMJD, applying moist heat on the masseter TrP a few times a day may ease the pain. Tell your patient to avoid chewing gum or hard chewy foods, and to chew foods evenly as possible on both sides of the mouth. Spray and stretch with ethylchloride or fluromethane to inactivate TrPs is described in detail in the Trigger Point Manuals. Ischemic compression using acupressure techniques is also often effective. Equilibration has a direct effect on TrPs, which have a direct effect on equilibration. Do not grind the teeth until the TrPs are eliminated.
Dental problems can often refer head pain or sinus pain. The pain amplification of FMS often has a direct effect in the dental chair. The dentist is a vital and integral part of the FMS&MPS Complex health care team. With awareness of FMS&MPS Complex symptomology and preventative care, much pain and trauma may be avoided.