Temporomandibular Disorders, Headaches and Chronic Pain

ABSTRACT

Temporomandibular disorders (TMDs) are a major cause of non-dental orofacial pain with a suggested prevalence of 3% to 5% in the general population. TMDs present as unilateral or bilateral pain centered round the pre-auricular area and can be associated with clicking and limitation in jaw movements. It is important to ascertain if there are other comorbid factors such as headaches, widespread chronic pain and mood changes. A biopsychosocial approach is crucial with a careful explanation and self-care techniques encouraged.

This report is adapted from paineurope 2014; Issue 3, ©Haymarket Medical Publications Ltd, and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, LTD and is distributed free of charge to healthcare professionals in Europe. Archival issues can be accessed via the website: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication.

KEYWORDS :

• temporomandibular disorders
• TMDs
• headaches
• mood
• exercise
• pharmacotherapy
• behavioral techniques

COMMENTARY FROM GERMANY

Charly Gaul

Temporomandibular disorders (TMDs) are often associated with headache and additional pain disorders, as described in this case report. There is some clinical evidence that migraine frequency increases in patients with TMD and there is also overlap with tension- type headache.¹ Psychosocial stress and psychiatric comorbidity (in particular depression and anxiety disorders) are more frequent in orofacial pain patients in general.²

In addition, there is a lack of data about the clinical picture and course of disease in persistent idiopathic facial pain, which may show some overlap with TMD and other orofacial pain syndromes.

Unfortunately, there is a lack of knowledge about primary headache disorders among dentists and a lack of knowledge about dental pain syndromes and TMD among neurologists. Therefore, an interdisciplinary approach is necessary for patients with orofacial pain syndromes.

Sadly, in real life, patients tend to meander between dentists, neurologists, pain specialists and physiotherapists to obtain different diagnoses and treatment recommendations without the interdisciplinary discussion that is greatly needed. The ideal setting would be a multidisciplinary orofacial pain clinic, where dental or neurological pathology could be excluded and the required somatic diagnostic evaluations performed, along with psychosocial assessment by experienced psychologists, in one interdisciplinary team. This would result in an individualized treatment plan for TMD and other orofacial pain conditions by experienced physiotherapists, psychologists, dentists and neurologists as well as pain specialists. Group sessions for education and guidance of the patients could complete the concept.

In this case, the diagnosis and therapy recommended by the author is completely right.

Dr. Charly Gaul is Director of the Migraine and Headache Clinic, Königstein, Germany.

COMMENTARY FROM SPAIN

Hermann Ribera

The cause of temporomandibular disorders (TMDs) is still unknown but it is considered multifactorial and includes both physical and psychosocial factors. In my opinion, in this case, the co-existence of other chronic diseases and work stressors with an anxious–depressive psychological profile may influence the development of chronic pain. As pain is multidimensional, consisting of sensory–discriminative and cognitive–affective experiences, TMD pain may be closely associated with abnormalities in central pathophysiological processing. A recent review has revealed that TMD patients showed a common pattern of plastic changes in brain function mainly in the thalamocortical pathways.¹

In this case, the high intensity of ongoing and breakthrough pain episodes makes the implementation of analgesic treatment mandatory. The nociceptive characteristics of the pain make the combination of paracetamol, NSAIDs and weak opioids suitable. However, because the breakthrough pain episodes are severe, another option may be transmucosal, sublingual or intranasal fentanyl, as the onset of action is fast and it should control the breakthrough pain.²

Evidence for other pharmacological options for TMD is limited; a Cochrane review included only 11 studies and there was inconclusive evidence for analgesics, benzodiazepines, anticonvulsants and other miscellaneous drugs.³ One open-label study of amitriptyline showed some benefit;⁴ whereas no benefit was noted in an RCT of botulinum toxin type A.⁵ Finally, psychotherapeutic support is critical to optimize analgesic outcomes in TMD patients.

Dr. Hermann Ribera is Director of the pain unit, Hospital Universitari Son Espases, Palma de Mallorca, Spain.

Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.