Facial Pain Determination

Facial pain can be caused by any number of different problems. Determining whether the pain is coming from the jaw joint (TMJ,) or the teeth, or the gums (periodontal disease) is important. So, I made a Facial Pain Determination Tree.

Since facial pain has many determinants, it is important to root out the cause of pain. The decision tree chart above helps winnow out the causes of the dental pain.

Cracked Tooth Syndrome:

If the pain is in the upper or lower jaw, and associated with biting pressure. If there is pain on release of biting, it is pathognomonic for cracked tooth syndrome. This often results because biting applies pressure to the tooth and sometimes biting hard may even temporarily feel good as it closes the crack, then, you release the pressure and you get a shot of pain as you release the tooth from it’s pressurized state, which momentarily causes the tooth to rebound and the crack to open up. When the crack is small, it is possible to cover the tooth with a crown and prevent the crack to further propagate. It is relatively common to see cracks extending vertically down the sides of teeth adjacent to large silver (amalgam) fillings. If the crack is deep into the root, then, the tooth often cannot be saved and will require extraction, which can be followed by dental implant placement and implant-supported crown.

Deep Cavities:

Commonly, the first sign a patient feels indicating a cavity is cold sensitivity. Often ice water (or cold water, or even cold air,) will pass across the tooth and the patient will get a momentary sharp pain in the tooth. Initially, this pain usually passes quickly. As the decay gets deeper into the tooth, the patient will likely start to feel sensitivity to hot items, like hot coffee or soup. Then, when the decay is so deep that the caries are sitting right at the brink of breaking through into the pulp chamber, then, the patient may even start to notice sensitivity to sweet or sour foods. Cold sensitivity does not always mean decay, as cold sensitivity can also be present in teeth with: exposed roots due to recession, or teeth that have recently had fillings placed. If the sensitivity is caused by caries (cavities,) then, filling the tooth will often solve the problem. The tooth may remain sensitive after having the filling completed for a few days, up to two weeks, or in unusual circumstances even 2 months. If the decay was very deep, the filling may require a dentin liner. If a dentin liner is used, it can be placed with a sandwich technique, where the dentin liner is placed over the area nearest the pulp chamber. This first layer acts as a thermal insulator. Then, a second layer can be placed with composite over the dentin liner, which will look and act like a normal filling. On root areas where sensitivity is found due to exposed roots, root coverage fillings can be effective in covering these areas. Because composite is very stiff, it is not an ideal material for root coverage fillings. Instead, for root coverage fillings to eliminate sensitivity, these are best covered using glass ionomer, as it increases in chemical bond strength to the tooth over time. Also, glass ionomer has a higher modulus of elasticity, so, when placed on tooth roots, it does not pop out from abfraction pressure caused by excessive grinding.

Root Canals:

A root canal therapy is a treatment to the internal aspect of the roots, which removes the nerves and blood vessels. A root canal is needed when the root of a tooth has died and become necrotic. A root canal is sometimes also required when a tooth has had deep decay that was treated with either a filling or a crown. If the decay approximates the pulp, essentially allowing the filling material to touch the nerves and blood vessels inside the tooth, the tooth may become irreversibly inflamed, which is called irreversible pulpitis. If the inflammation goes away, it is termed reversible pulpitis, because the pulp goes back to its healthy state. When a tooth has been prepped for any type of restoration, it may require a root canal. It is particularly common for a tooth that has been prepped with inadequate water to become overheated. So, copious water use during crown or filling preparations is important to allow the tooth to remain cool. The success rate on root canals is approximately 95%, on the first treatment. Anterior teeth are easier to treat because they have fewer canals than molar teeth. Maxillary 1st molars are notoriously the most difficult teeth to treat because they frequently have a 4th canal called the MB2 canal, which is often difficult to locate and clean out. These teeth are often best treated with the aid of a microscope because it allows the dentist operator to see the MB2 canal.

Gum Surgery (Periodontal Surgery)

One other reason a person might experience a draining abscess, or fistula with pus could be of periodontal origin, gingival origin. Gum disease is caused by a cascade of effects. Periodontal Disease is the cascade of effects that usually starts as heavy build-up (tartar and calculus,) which gives the bacteria a place to live. The bacteria colony gradually changes to aggressive bacteria (gram negative anaerobic bacteria.) This more aggressive bacteria causes an autoimmune response in the patient, which leads to bone loss, bleeding, and pus. The open wound in the periodontal pocket allows this bacteria to enter your bloodstream, and increases your risk of heart disease, diabetes, and other diseases of inflammation (osteoporosis, and Alzheimer’s). You can reverse periodontitis with treatment that ranges from SRP (Scaling and Root Planing,) Antibiotics, Surgical Periodontal Treatment, Bone Grafting, and Laser Therapy. At home for maintenance, you may use hydrogen peroxide trays, Chlorhexidine mouth rinse, or even a mixture of 3 drops of bleach mixed into a full water tank in a Waterpik.

Night Guard & Sleep Apnea

If a patient has Temporomandibular Joint Dysfunction (TMJD,) their jaw is often clicking and popping in the joint space with pain. If your jaw joint clicks, without pain, this is a sign of a physiological pop. The disc is recapturing when the click is heard. This click is consistent with lateral displacement of the TMJ disc, (articular disc.) When a patient starts to feel that they can’t bite down all the way, even when there is nothing in their mouth. This is a sign of disc displacement, without recapture. What is likely happening when a patient’s teeth won’t fit together at rest is simple. The disc is displaced, and now instead of the lower jaw fitting into place correctly, which is resting on the disc, the supporting ligaments and muscles are pulled into the space where the disc is supposed to be. Chewing, talking, and swallowing cause the patient to apply pressure to the muscles and ligaments, where normally there would be a disc to rest on. Eventually, the displaced tissues become inflamed from the constant aggravation of being bitten on. Now, the patient goes to bite down, but, the side of the jaw where the tissue is both displaced and inflamed prevents the patient from being able to bite down all the way, but, instead they now have an open-bite on the side of jaw which has experienced the prolonged displacement. The jaw can be physically manipulated open with the gentle guiding hands of the dentist (open, then, capture the disc by moving the jaw until the disc is back on the condyle, then, guide the whole jaw posteriorly and superiorly,) it sometimes takes 2-3 times before the disc decides to go along. Then, the patient should be put on a soft diet, with NSAIDs (usually ibuprofen,) complemented by a muscle relaxer (Tizanidine 10mg)(for a short time as needed to eliminate spasms,) and a night guard where appropriate.

It should be noted that damage to the Temporomandibular Joint (TMJ) can be caused by several factors. Let’s review the top 3 causes of TMJD:

1. Grinding and Clenching: TMJD was traditionally thought of as a disease of attrition and damage induced primarly by bruxism. It is very common for a patient going through major life changes to arrive at the dental office with a complex set of problems, from tooth sensitivity, pain in the jaw, pain in the ear, pain in the facial muscles (especially the masseter muscle), headaches that start around the temples (temporalis musle.) These patients are often clenching and grinding. Some of these patients are already aware that they clench during the day, especially if they are self aware of their triggers, such as work relationships, driving, or family situations. Many patients wake up in the morning and notice increased stiffness in their jaw, which is classic for bruxism (night grinding.) Patients may notice these symptoms start to occur after they have gone through one of the 3 major life changes: •job status change, •relationship status change, •moving. If the patient falls into this broad category of clenching and grinding TMJD, then, a traditional night guard may improve their symptoms.
2. If a patient suffers an injury from sports, or an automobile accident, they may recover without intervention using NSAIDs (e.g. ibuprofen.) If the injury is severe, it may require a surgical intervention. Sometimes the jaw may feel fine for a while, and only much later does the patient realize and discover that their jaw was injured. Injury cases may require ongoing care and regular re-assessment over the rest of the patient’s life. A night guard may or may not be appropriate depending on the type of injury and the type of displacement being caused. If granulation tissue starts to impinge the movement of the jaw, an arthrocentesis with joint space flush using sterile saline may be an appropriate intervention.
3. Sleep Apnea (OSA, obstructive sleep apnea) is a serious disorder in which a patient is stopping breathing at night during sleep. One of the causes of sleep apnea is being clinically overweight, with significant increases in morbidity and mortality for obese individuals. When a person’s BMI is over 30, they are at increased risk of OSA Syndrome. When a person’s BMI is over 35, they are at high risk of developing OSA Syndrome. When a person is sleeping and their airway closes off, they stop breathing, which causes the patient to wake up gasping for air, forcing them out of the deep restorative sleep they were in. Now, a few things happen: •the patient often starts grinding their teeth to create and airway, •the patient gets a major dump of cortisol – the stress hormone, which causes weight gain, •the patient’s blood pressure spikes, and this leads the patient to have higher blood pressure daily as well since they are gaining weight and training the heart to have to work harder since the oxygenation is chronically problematic during sleep, •the patient is likely experiencing oxygen saturation dropping events, during sleep the spO2 on these patients can drop below 95%, and in some extreme cases below 90% or even lower. For patients who may be suffering sleep apnea symptoms, they should be tested with an overnight sleep study to assess their spO2 overnight. If these patients can tolerate it, then, they may like to wear a CPAP. At 1 year the success rate for CPAP is 49%, because they are cumbersome to wear. If CPAP fails the patient, a TAP-3 appliance can be made to advance the jaw and open the airway. Intraoral dental appliances are fitted to the patient, and they often provide a comfort level that cannot be matched by a CPAP. Some patients would do well to have both a CPAP, and wear an intraoral dental appliance (mandibular advancement splint, MAS.) It should be noted that if a patient receives a TAP-3 appliance, and commits to Oral Appliance Therapy (OAT,) they should also note that they will be expected to wear an AM aligner to put the jaw back into their normal occlusion and correct back to their normal bite in the morning. I do not want to make a TAP-3 appliance for someone who is not prepared to wear an AM aligner every morning for 30-minutes to an hour every morning. The patient should be committed to treating the OSA syndrome by wearing the OAT, but, also committed to wearing the AM aligner.

Crowns:

Crowns are commonly called caps. They can be thought of as a replacement of the outer shell of the teeth. Sometimes we will describe them as a top hat for the tooth. The crown acts as a replacement of the outer layer of the tooth, effectively they are an enamel replacement. Crowns are used for a variety of reasons: •if a tooth has a crack, such as in cracked tooth syndrome, and the tooth is fracturing vertically down the side, •if a tooth has broken off a large piece and the remaining tooth structure is severely damaged, •if a tooth has a large filling that has additional decay, and there is so little tooth structure left that trying to replace that filling with a new filling would leave the tooth terminally damaged and at risk of immediate fracture, •if a posterior tooth (molar or premolar) has had a root canal, •if a tooth has caries and an adjacent portion of tooth structure broke off due to undermining decay, •if a tooth has some other condition, which warrants the use of a crown to allow for ideal form, function, and longevity.

Shingles (Herpes Zoster) and Cold Sores (Herpes Labialis):

Shingles will almost always cause dental pain if the virus Herpes Zoster has chosen cranial nerve five (CN. V) as it’s preferred hiding spot. The pain is usually lancinating (shock-like) when emanating directly from the nerve body. There are often red, ring-like welts in the mouth that start as burning, bubble-up and then, pop. The pain is always on one side of the mouth only (unilateral.) The pain can be confusing since it is known to come and go. It can affect upper teeth and emanate from the sinuses. It can affect the lower arch and emanate down the jaw. It can affect the palate. It can affect a few individual teeth, especially upper molars, close to the sinuses. It can affect the cheek, and area below or above one eye. The reason that it comes and goes is that the body keeps it in check when the body is healthy. If the immune system is called into action to fight off an infection in some other part of the body, then, the immune system may temporarily have to redistribute its resources from keeping the shingles in check. Then, about the time the patient is recovering from some other issue (think: skin infection, upper respiratory infection, or other ailment,) then, they have an outbreak of their shingles.

Cold Sores are painful and frustrating and recur similar to the shingles described above. The good news for both cold sores and shingles is that there is an effective treatment. In my experience, if the patient is getting cold sores 2x – 3x per year, then, the ideal treatment is Valacyclovir 500mg, 4 pills taken at the first sign of symptoms and 4 pills 12-hours later. (In this dosing, each pill is 500mg, and the dosing is therefore, 2g at the first prodromal symptoms, with 2g following 12-hours later.) This dosing protocol works best when the patient has the pills available at home or at their office, so that the pills can be taken right away before any boil/bubble forms. Usually, patients will experience either: burning, itching, or some other sign, this should tip them off that they are about to get a cold sore, and then, they should quickly take the first dose of the medicine to prevent the sore from forming. The goal in this therapeutic dosing is to eliminate the cold sores from ever getting the chance to form. If you follow this protocol, you can essentially eliminate all cold sores from ever wreaking havoc on you.

Alternatively, if a patient has chronic herpetic lesions, 10x per year, or shingles that are chronic, then, we might consider a different dosing strategy. I will consider knocking the virus back using Valacyclovir 500mg taken 1x/day for 2 month, dispensing 60 pills, and reduce the overall viral load. Then, after that initial dosing, we could switch to the previous plan of treating viral events as they come with 8 pills taken following the schedule above. Immunocompromised patients may require ongoing maintenance dosing with Valacyclovir 500mg daily to prevent recurrence of viral outbreaks within the affected dermatomes.