Assessing Intra-Oral Trigger Points in Craniofacial Pain DisordersPrint
According to statistics, muscle dysfunction accounts for 85 percent of all pain syndromes. This is especially true for those suffering from craniofacial pain, including TMJD, headaches and atypical face pain. Patients presenting with head, neck and jaw pain are sometimes challenging as there can be multiple components to assess and treat.
According to the National Institute of Dental and Craniofacial Research, the most common form of TMJD is myofascial pain, yet it is not taught in dental schools. In addition to bite splints, dental professionals use modalities such as biofeedback and medications to relax the muscles. Attempts to relax the muscle simply cause an active trigger point (TP) to become latent leaving the impression that all is well.
It has been an enormous challenge to teach the dental community the difference between "relaxing" muscle and "releasing" muscle dysfunction. Because latent TPs (not causing an active pain complaint) can still decrease range of motion, weaken the muscle and pull on bony attachments, it is important that we not only correct the myofascial component, but also teach the patient how to self-treat when TPs become active again, causing myriad painful symptoms and referred pain. There have been many scientific and clinical publications pointing to TP infestation as either the central cause or significant contributor to painful syndromes and myofascial disorders such as seen in TMJD and other craniofacial pain.1-5
Intra-Oral Trigger Point Release
Intra-oral TP work is slowly becoming more common in therapy practice but is not the norm for therapy curriculum in our massage and PT schools. There are five major muscle groups found inside the mouth, which also include other surrounding muscles. Figures 2-5 are the pain referral patterns found in Travell & Simons Trigger Point Manual (TPM). The tensor veli palatini and internal pterygoids located in the roof of the mouth can be the cause of tension type headache, pain behind the eyes and sinus pressure.
Dr. David G. Simons, MD agreed with the referred pain patterns shown in Figure 6 although this particular one is not found in the current TPM. TPs are palpable contraction knots or taut bands that will ultimately change or alter muscle tension leading to secondary problems of internal derangement, arthritis and/or faulty joint mechanics leading to ultimate joint erosion and breakdown.6 Whether primary or secondary, the presence of TPs can perpetuate disability and worsen the prognosis if they are not considered and treated. An intricate pathway of nerves and blood vessels runs through the muscles of mastication. Any disruption of normal function can lead to severe pain.
Personally, after suffering a whiplash and closed head injury in a motor vehicle accident, it not only exacerbated a pre-existing TMJ disorder, but also caused me to have headaches around the clock. There seemed to be no medication or solution to help ease the pain and I was convinced by an oral surgeon that I needed a complete reconstructive jaw surgery. Not only did the surgery not work, but it also made the pain worse, as I endured yet another two years of braces to correct the bite.
Desperate for help, I asked for a physical therapy referral and was incredibly fortunate to find a PT well versed in treating TMJD and headaches. She taught me how to self-treat using intra-oral TP release techniques, and for the first time, I experienced true pain relief that surprisingly was almost immediate.
Because the treatment was so profound, I began teaching and treating others while continuing research efforts. It soon became evident that both reaching these muscle groups and following the release response all the way through was near impossible with the fingers and thumbs alone.
The MyoFree® Solution
Based on years of research and product development, the patented MyoFree® Solution was born. The self-help "kit" consists of the easy-to-use MyoFree® massage tool and the easy-to-learn, Inside-Outside™ technique. The instructional DVD uses 3D animation of the muscle groups to teach the location and treatment of intra-oral TPs using ischemic pressure. A full-color Quick Start Guide is also included showing an open mouth diagram and written instructions to compliment the video. A carrying case is also included for travel and safe storage.
Inactivating the TPs from both sides, if possible, renders much more effective results. Also a problem with most patients is the inability to treat the tensor veli palatini and internal pterygoids found in the roof of the mouth without eliciting a gag reflex. The MyoFree® massage tool (See Figure 7) is small in diameter which allows even those with severe hypomobility of the TMJ to self-treat. One end of the device is shaped like a golf-tee and mimics the thumb. The other end is a very small ball and was designed to treat the attachment area of the lateral pterygoid which is located in a very small anatomical notch. Practitioners often complain that they can't even reach this area with their pinky finger as it is so small and hard to reach.
Most therapists consider Dr. David G. Simons, MD to be the "father" of TP therapy since he co-wrote the Trigger Point Manual with Dr Janet Travell. After watching the DVD and using the MyoFree® massage tool on himself, Dr. Simons wrote a 2 page testimonial to the dental profession on the importance of intra-oral TP release and why the MyoFree® device is so effective. His testimonial and other resource materials can be found at www.tmjpainsolutions.com.
Tiziano Marovino, DPT, DAAPM, was able to document by diagnostic ultrasound a TP in the masseter muscle (see Figure 8) before and after treatment proving that the MyoFree® works. Larry L. Tilley, DDS, from Calhoun, Georgia has done multiple outcome studies showing the relationship of bite mechanics both pre and post release of muscle dysfunction. The changes are quite remarkable and it's easy to see from the changes in bite impressions how the cranial sutures could shift as well and why headaches are so prevalent in TMJ disorders.
In a study involving 300 patients who all had been involved in a motor vehicle accident, the most common clinical findings indentified on medical evaluation were the following; jaw pain, neck pain, post-traumatic headache, jaw fatigue, and severe TMJ crepitus or clicking. The most common diagnoses in order were: masseter muscle trigger points, closing jaw muscle hyperactivity, and advanced disc derangement.7
Headaches and Atypical Face Pain
Intra-oral TPs are often the underlying cause of pain in these conditions (some statistics show that 80 percent of ALL headaches originate in the muscles of mastication) but our society is more versed in prescribing medications which cover up the actual "source" of pain. Nothing is quite so gratifying as watching a patient diagnosed with trigeminal neuralgia discover that their pain is actually from a TP compressing a nerve and not true nerve damage. I've witnessed several patients get off multiple anti-seizure medications prescribed for nerve pain that they didn't require in the first place. It is my personal goal that intra-oral trigger points are ruled out before giving a patient a hopeless diagnosis of trigeminal neuralgia or tic doulourex.
The MyoFree® Solution is a life-long, self-help, pain-relief system that teaches patients how to self-manage their pain symptoms for the rest of their lives. The real beauty of the system is that anyone can easily learn the techniques. Whether you're a practitioner who would like to learn the techniques to add a new modality of treatment to your current practice or to simply re-sell the product to your patients, you can and hopefully will, learn and/or share the techniques.
Anyone who has suffered a head injury, whiplash, has TMJD and/or headaches should be made aware of the self-help techniques. We pride ourselves on comprehensive home programs and providing knowledge that empowers a patient to become involved in their own wellness. The presence of TPs can be primary or secondary, but either way, can perpetuate disability and worsen the prognosis and interfere with primary interventions if not considered and treated. Left untreated, TMJD can become progressively worse and cause permanent damage within the tissues.
Trigger points have a sensory component but can also manifest as tension altering entities which, over time, can lead to uneven bite mechanics and restrict mouth opening.8 Research shows that TPs are a common component of diagnoses related to the head, neck and jaw. Intra-oral TP release has a huge impact on not only the muscles of the face and jaw, but also has a remarkable cervical component. Any therapy that can eradicate or control TPs should eventually become a standard part of the total treatment intervention for these difficult to treat conditions.
The MyoFree® Solution is available at www.pressurepositive.com and retails for $59.00. Wholesale and health professional inquires are welcome; call 800-603-5107.
- Simons, D., Travell, J., & Simons, L. Myofascial Pain and Dysfunction-TheTrigger Point Manual, Volume 1, 2nd Edition, Lippincott Williams and Wilkens.
- Fricton, J. Masticatory myofascial pain: an explanatory model integrating clinical, epidemiological and basic science research. Bull Group Int Rech Sci Stomatol Odontol. 1999. Jan-Feb; 41 (1): 14-25.
- Alverez, D., & Rockwell, P. Trigger Points: diagnosis and management. Am Fam Physician. 2002. Feb 15; 65(4):653-660.
- Mackley, R. Role of trigger points in the management of head, neck and face pain. Funct Orthod. 1990. Sept-Oct; 7(5):4-14.
- Fricton, J., Kroening, R., et al. Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients. Oral Surg Oral Med Oral Pathol. 1985. Dec; 60(6):615-623.
- Peroz, I., & Tai, S. Masticatory performance in patients with anterior disc displacement without reduction in comparison with symptom free volunteers. Eur J Oral Sci. 2002. Oct; 110(5):341-344.
- Friedman, M., & Weisberg, J. The craniocervical connection: a retrospective analysis of 300 whiplash patients with cervical and temporomandibular disorders. Cranio. 2000. Jul; 18(3):163-167.
- Djkstra, P., Hof, A., & Stegenga, B. et al. Influence of mandibular length on mouth opening. J Oral Rehab. 1999; 26:117-122.
Gail Falzon is a myofascial practitioner who specializes in craniofacial pain disorders. She treats patients in southeast Michigan, teaches other professionals and speaks at national conferences for therapists and other medical/dental clinicians that work with TMJD, headaches and atypical face pain. She is the founder of TMJ Pain Solutions and the Inventor of the MyoFree® Solution. More information can be found at www.tmjpainsolutions.com and www.facebook.com/tmjpainsolutions.