Oral Facial Pain

A different approach to solving oral facial pain

Physical Therapy for Temporomandibular Dysfunction

A Case Study of Myofascial Pain Dysfunction

OBJECTIVE:   To describe the use of physical therapy to resolve oral-facial pain of non-tooth origin

BACKGROUND: The patient was a 65 yr old female who presented with intense, intermittent pain radiating from the right ear to the mid-chin of four months duration.  Tooth pathology had been ruled out by two dentists.

METHODS:   Physical therapy evaluation to identify causative factors; military posture, occipital hyperextension, active trigger points of the pterygoids and the masseter were primary findings.  A mild right joint click was noted with jaw opening.  Treatment consisted of postural correction, body mechanics instruction, pulsed ultrasound over the right temporomandibular joint and exercise instruction.  Stretching of the masseter and pterygoids along with inhibitory icing were the interventions chosen to resolve the trigger points.  TMJ self-mobilization instruction was given to resolve the joint click.

RESULTS :  This patient had complete resolution of her lateral jaw pain and was able to resume brushing her teeth, flossing and eating normally, without symptoms.

CONCLUSION:   The physical therapy treatment provided to this patient resulted in complete resolution of her symptoms. 

Postural correction helped resolve chronic repetitive stress injuries resulting from hyperextension of the occiput.  Gentle joint manipulation stretched tightened joint ligaments.  Most importantly, correct stretching of the pterygoid and masseter muscles eliminated active trigger points, the primary cause of pain.

Discussion:
Faulty postural habits are often the contributing factors in oral-facial pain.  In this case occipital hyperextension related to military posture was a precipitating factor.  Palpation of the masseter and medial pterygoid revealed exquisitely tender trigger points and taut bands.  These trigger points referred pain towards the ear and jaw.  Illustrations A, B and C indicate the referral patterns of these muscles as interpreted by Janet G. Travel, MD and David G. Simmons, MD in Myofascial pain and dysfunction:  The Trigger Point Manual, Vol. 1, The Upper Extremities (© 1983, Lippincott, Williams and Wilkins.)

As noted, these pain patterns could easily appear to originate in the teeth.  The patient was afraid to brush or floss her teeth as movement, including talking, could trigger excruciating pain.  Once the patient understood the mechanism causing her pain she could initiate stretching at onset and shorten the length of the pain episode.  Upon discharge, the patient was pain free and had returned to normal activity.

Initially the patient was seen for nine sessions with good resolution of symptoms.  Six weeks later the patient called with complaints of a recurrence of symptoms.  Upon evaluation it was noted that the patient was stretching much too aggressively.  Exercises were reviewed with careful instruction as to force and frequency.  the patient was discharged after four additional sessions pain free.  The patient, a retired nurse enjoys writing as a hobby.  Her abridged account of treatment follows.