Why do our patients have orofacial pain? Six steps of discovery.

I recently recorded a video outlining six possible indicators of an actual TMJ disfunction, which you can view at the end of this article. The following is based on the information in that video.

If you were to do an internet search on “Prevalence of Orofacial pain” you would see numbers ranging from 10% to as much as 30%. The October 2015 Journal of the ADA cited a figure of 16.1% with female patients complaining of these painful problems nearly twice as often as men.

As interesting as that may be, I am more interested in the reasons why. And discovering why a patient is experiencing these pain syndromes takes a bit of sleuthing. The video, as well as this article, are only composed of screening steps. That is, screening is not diagnosis; it is only a first step. But if the patient fits one or more of the possible indicators of an actual TMJ disfunction, then clinical exam, including evaluation of occlusion, joint imaging, evaluation of joint vibrations (joint sounds), etc. should follow.

Other possible causes of orofacial pain that are not related to the health of the Temporomandibular joints include emotional stress, sleep apnea, occlusal problems, cervical (neck) pain and even foot pain leading to postural changes. A sorting out process, that is, looking at differential diagnosis needs to be part of the plan.

Some years ago now, a Southern California dentist attended one of my presentations on these screening steps for possible TMJ disorders and immediately thought of one of his patients, a man named Kenny. Kenny’s chief complaints were frequent headaches and difficulty opening. He referred Kenny to me. Here’s a photo of Kenny’s severely worn dentition.

One possible cause of this kind of wear is sleep apnea, and in fact in may have been a factor, however Kenny is using a CPAP machine and does not seem to be bruxing due to his sleep apnea.

On palpation exam I found that Kenny had severe pain in the temporal tendons, the right masseter muscle, the right anterior temporalis and the right occipital area. His maximum opening was 34 mm. Joint imaging showed posterior displacement of both mandibular condyles.

Producing proper joint architecture, that is putting the condyles in proper position within each glenoid fossa, meant about 2 mm of protrusive repositioning of the mandible along with significant increase in vertical dimension.

If you’re a dentist, I’m sure you could imagine the result if you used this vertical in your restorative plan: yes, the incisal edge length should get Kenny’s front teeth back to what they looked like prior to his severe wear.

Looking at the treatment appliance that I made for Kenny, you might wonder why I didn’t cover the anterior teeth. Certainly, the Dawson Academy and others would advocate a full coverage splint. While I do have specific reasons for leaving the anterior teeth uncovered, I will save that for a later discussion.

Kenny wore this appliance when awake, including eating. I made an anterior deprogrammer, similar to a Kois deprogrammer, for sleep. Within a relatively short time, less than one month, Kenny’s headaches were gone and he had normal range of motion, greater than 42 mm opening with no pain. Kenny reported that he was able to eat with the appliance in place with no pain or problem.

I have my own protocol for full mouth restorative, and while I won’t describe it here, I can tell you that after a few preliminary steps (crown lengthening surgery on the anterior teeth and implant placement #30), the restorative process was completed in four visits, two weeks apart.

Here are photos of Kenny fully restored. If you recall how damaged his natural teeth were, you can imagine that I had some concern about going to all-porcelain restorations. And yet, it has now been several years since these restorations were placed and he has not chipped or broken any of them.

Perhaps this is a reason ‘why’ for you; if you’re a restorative dentist and would like to perform more comprehensive dentistry, I recommend a close look at screening for and diagnosing TMJ disorders. The TMJs after all, are the foundation of occlusion and therefore the very foundation of your dentistry.

Here is an example of a healthy joint, with the condyle centered in the glenoid fossa. I know that some of today’s authorities prefer to place the condyle forward of this position, in Pete Dawson’s words “with the condyle-disc assembly braced against the eminence.” And I won’t argue with that. However, when the condyles are posteriorly displaced, relative to this healthy centered position, there is often dysfunction and pain.


Here is a slide of a person with an anterior disc displacement and the condyle forced back against the ear.

There are six common things that happen when the joint is in this configuration. First, many of these patients have headaches, in fact they may list headache as the chief complaint.

Limited opening is another common finding. This can be because the disc limits the translation of the condyle, but in addition, the muscles of mastication can be severely tense or even in spasm. A maximum opening of 35 mm or less is very common for folks with this kind of joint architecture.

Clicking and popping is a frequent complaint. This person has a reciprocal click meaning that the joint clicks on both opening and closing. The condyle translates forward onto the disc and clicks off the disc when closing.

Pain when chewing is often mentioned by these patients. This patient has pain upon closing because the condyle presses on tender retrodiscal tissue in the closed position. The disc itself is composed of tough fibrocartilage that is not innervated. With the disc in place, you can place upward pressure on the joint with no pain, but the retrodiscal tissues are quite tender and pressure on them is painful.

Ear pain is common with the condyle posteriorly displaced. Pressure just in front of the ear can easily mimic an earache. A couple of local ENTs were among our more regular referral sources because patients would present with the symptoms of ear infection, but the doctors would find no ear problem at all.

One complaint that may seem odd is pain behind the eye. In a later presentation I can review the anatomical reasons for this, since the displaced condyle and area behind the eye seem unrelated, and yet there is a connection.

Are there more than six areas to be aware of in the screening process? Yes, but these six were the most observed in my practice:

  1. Headache
  2. Limited opening
  3. Clicking and popping
  4. Painful chewing
  5. Ear pain
  6. Pain behind the eye

As far as exploring these issues further, what’s a possible WHY for you? That’s something only you can answer. But keep in mind that a TMJ disorder will cause your patient’s occlusion to be unstable and these screening steps followed by diagnosis can lead you to more comprehensive dentistry.

Omer Reed, an excellent teacher in dentistry and at one time considered the most famous dentist in the world, always said he wanted his dentistry to look good, feel good, and last a long time. If those sound like goals you’d like to achieve for your patients, you will want to be sure that the joints themselves are stable—perhaps a reason to look into these areas a little more in depth.

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