Managing Craniofacial Pain the Multi-Disciplinary Way
Noshir R. Mehta, BDS, DMD, MDS, MS
What is now the Craniofacial Pain Center of Tufts University School of Dental Medicine was originally founded in 1976 as a very small clinic with just two employees—the author as the dentist and Albert G. Forgione, PhD, as the psychologist—treating patients with temporomandibular disorders. However, as a result of successfully using a multi-disciplinary approach to treat these conditions and because the clinic was part of an educational institution, it made sense to respond as educators and scientists to the interest shown in the clinic’s work. By developing courses to teach others how to do what the clinic was doing and conducting studies to verify the results, the small clinic could help fellow dentists, medical colleagues, and patients in a greater way than by simply individually consulting on their cases.
Today, the Center is one of the largest of its kind in the United States. Devoted to the diagnosis and management of temporomandibular disorders; chronic head, neck, and facial pain; and sleep disorders the Center incorporates true multidisciplinary approaches to the treatment of complex pain problems. The team includes pain physicians, sleep physicians, dentists, an acupuncturist, a chiropractor, physical therapists, psychologists, and an occupational therapist. Treatment approaches range from dental bite appliance and other dental therapies, medications, stress management, counseling, physical therapy, trigger point therapy, and neurological treatment for headaches and dental sleep disorders.
The main reason this multi-disciplinary approach has proven so successful is that pain management is so complex; there is often more than one cause for the pain complaint, and the pain itself leads to other issues, including depression and sleep disorders. Therefore, the Center consists of three divisions. In addition to the Craniofacial Disorders Center, the Dental Sleep Disorder Center is devoted to the multidisciplinary management of sleep-disordered breathing—including obstructive sleep apnea (OSA) syndromes, which are associated with drops in oxygen level, arousal, and fragmented sleep. Additionally, the Headache Disorder Center focuses on the number one patient pain complaint. Other complaints include bite problems, temporomandibular joint pain, joint sounds, facial pain, eye problems, ear problems, neck/throat pain, and related back problems.
It is important to be aware that with most patients with temporomandibular disorders, part of the problem is a medical model and part is a dental model. The dental model focuses on physical medicine, which includes jaw positioning and appliance therapy. The medical model incorporates the use of medication, psychotherapy, and psychological support services for people in chronic pain. Such patients are often dismissed as mentally ill by specialists who are unaware that clinical depression is common among chronic pain patients and that effectively relieving their pain may cause their depression to lift as well.
At the Craniofacial Pain Center it is believed that incorporating physical medicine into the system makes treatments more effective. In courses at the Center, dentists are taught that they have a greater ability to understand and treat these issues than they realize, because as they open and close the patient’s mouth as part of procedures and routine care, they are constantly dealing with muscles that cause the pain, including headaches. Interestingly, people with deep bites generally have neck symptoms, which are treated in the Center by increasing vertical dimension of the occlusion with appliance and physical therapy combination rather than just with medication.
The use of a dentist-prescribed bite appliance between the teeth is effective for treating headache pain, because headaches are generally muscular-skeletal in nature and the muscles of the head and neck region are typically treated by dentists. Thus, patients given a nightguard for bruxing may wake up the next day without the early morning headache because they have not been clenching their teeth all night long. Jaw positioning can also be used to enhance medical treatment in patients whose pain stems from sleep problems—especially when use of a continuous positive airway pressure (CPAP) machine is not an option—as it can improve the airway during sleep in much the same way that a restricted airway is opened using the cardiopulmonary resuscitation (CPR) technique.
The author believes that orofacial pain and its management will ultimately become a recognized specialty. At Tufts, there is now a 2-year training program—a certificate program much like any other specialty—as well as a 3-year masters program, which also includes research to train dentists to treat, teach, and further their understanding of this complex problem through research.
About the Author
Noshir R. Mehta, BDS, DMD, MDS, MS
Professor and Associate Dean
International Relations at Tufts University
Department of General Dentistry and Director
Craniofacial Pain Center of the Tufts School of Dental Medicine