Caring for Face Pain and Sleep Apnea
Rich Hirschinger, DDS, MBA
Diplomate American Board of Orofacial Pain
9615 Brighton Way, Suite 323
Beverly Hills, CA 90210
888.981.8981
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An Anniversary, A Single Day on a Bike, And Two Valuable Life Lessons

Posted on: July 22nd, 2014 by Dr. Rich Hirschinger 1 Comment

This is a story about an anniversary, which occurred today, and a single day on a bike, which occurred three days ago. I hope you get something out of it because I did and I think the thoughts and experiences are worth sharing.

Today, July 22, 2014, is the five year anniversary of my double spinal fusion surgery at L4-L5 and L5-S1, which is why I wear a CamelBak even on a road bike. L4-L5 and L5-S1 are the two lowest vertebrae in your back. I like to say that I was screwed five times in one day, and I can prove it. Prior the day of the surgery, I could not get my own socks on or off or tie my own shoes.

The left side shows the herniation of L4-L5, and the collapse of L5-S1. The middle and right images are the spinal fusion screws.

The left side shows the herniation of L4-L5, and the collapse of L5-S1. The middle and right images are the spinal fusion screws.

I was an avid cyclist before my back was injured, which originally occurred when I was rear ended by a van while riding my bike. I was thrown of the bike onto the sidewalk and slid over 20 feet before coming to a stop right before a concrete light pole. That accident eventually led to a microdiscectomy at L5-S1 in 1999, and I was fine after that procedure. Then, in 2007, I was driving my car with my daughter in the back seat when a driver ran a red light and hit us as I was turning. That led to the double spinal fusion and I stopped riding my bike for several years until I caught the “bike bug” again at the end of October 2013. It felt great to be back on the bike but I was hit again by a driver who made an illegal U-turn when I was traveling straight in December 2013. I have never needed my bike helmet like I needed it that day, which was also on the 22nd of the month. My head bounced off the street after I ran straight into the car’s driver side rear door. I have always said, “there is only one reason to wear a helmet, which is if you have a brain,” and I basically walked away from that accident with sore ribs, some back pain for a few months, and a scar on my right knee.

After I recovered from that accident, I started riding even more. I rode my longest ride ever, a 117 mile journey from Los Angeles to the campus at UCSB to visit my daughter who was finishing her first year in college. That ride was six days before the murder rampage in Isla Vista that took the lives of six UCSB students.  This past Saturday, one of my friends in Velo Club La Grange, which is my local cycling club, wanted to go on a long ride with a lot of vertical climbing. The ride ended up being over 107 miles long with over 9,000 feet of climbing but it is what happened on the ride that is important. I use Strava, which lets you track your activities along with your friends activities, and I was very surprised that I had the longest ride of the week last week for my cycling club, which is something I would not have envisioned five months ago let alone five years ago.
La-Grange-Leaderboard
About 12 miles into the ride, we had to take a detour on Pacific Coast Highway (PCH) since the road was closed due to a very tragic decision a young lady made. Those of you that ride PCH in Santa Monica will notice the squiggly line indicated by the yellow arrow on the map below, which is the detour we had to take through the Bel Air Bay Club up to Sunset and then back down to PCH.

Map-detour-600
The young woman, who was in her 20’s, tried to cross PCH at 3:30 a.m. That was likely the second to last thought she had since she was hit by a car, which is why the road was closed. She died from her injuries the same day. It was not lost on me the split second decisions we make during our lifetime, which in this case, was a fatal decision. Take the time to really think your decisions through. Some thoughts are not work the risk.

From PCH we climbed up Topanga Canyon to Mulholland Drive then back to PCH via Malibu Canyon, then back up to Mulholland via Encinal Canyon. At Mulholland and Malibu Canyon, which was at mile 72 give or take a few tenths of a mile, my friend saw one of his friends on the side of the road with a flat tire. We stopped to help, and coincidentally there was a NBC News reporter interviewing a cyclist about a video rant that had been posted online by a reserve police officer for the Santa Paula Police Department. The video was about how much she hated cyclists, and how much the driver of the car she was in would charge to run them over. Some people think this is merely freedom of speech. Others think it is very disturbing that anyone, let alone an officer of the law, would suggest running over cyclists with a car.

Jane Yamamoto was the NBC News reporter who interviewed me as well as a few other cyclists to get our opinion on the video, which  you can watch below.

The decision made by the reserve police officer to post her video took several hours since the video had to be conceived, filmed, edited, and then posted. It was not a split second decision. But the decision cost her her job since the Court of Public Opinion convicted her of horrendously poor judgment, and she ended up resigning from her position. What astounded me is that she is a personal trainer yet she hates cyclists even though they are outside exercising, which is what she has her clients do for a living.

I’m very happy with the decision I made five years ago to have my back surgery done. Some people question my decision to continue to ride my bike since I have been hit by a vehicle twice. I feel good about my decision since riding my bike makes me feel alive, and we have to live when we are above ground. Take the time to make good decisions in your life. Quick decisions can cost you your life, and other decisions that you think are the right decision at the time can turn out to cost you as well.

Lastly, don’t make excuses for why you can’t do something. The mind is a very powerful tool. You can talk yourself into not doing something or you can talk yourself into doing something. Anything worthwhile is going to be hard work. Which is why work is a four letter word. Be safe, have fun, and take advantage of the time you have. It is a very precious gift.

Dentists Should Not Use Botox For Chronic Pain

Posted on: May 12th, 2014 by Dr. Rich Hirschinger 6 Comments

Yes, I admit the title is somewhat misleading but not by much. What is missing is the word “first.” A dentist, or any physician, should not use Botox as a first choice to treat patients with chronic head and neck pain and/or headaches. I believe that if Botox is used, it should be used last. I do use Botox to treat patients in my private oral facial pain practice in Beverly Hills, CA but if I do use it, I use it last after I have tried other more effective and less expensive treatment options.

If the doctor suspects the cause of their patient’s pain is muscle pain, he/she should try several things before using a medication that might or might not work, that is extremely expensive, and that lasts for about three months. If the diagnosis is not correct and/or if the Botox does not work, the patient spent a lot of money, and the effect of the medication will last for several months.

What can be tried first? The first, and most important step is to establish a diagnosis. If the doctor can replicate the patient’s pain with muscle palpation, then a diagnosis of myalgia, which is muscle pain that does not refer to a remote site, or myofascial pain, which is muscle pain that does refer to a remote site, can be made. I recommend trying basic physical therapy that the patient can do at home. Basic jaw and neck stretching exercises are a great place to start, and I routinely give my Beverly Hills chronic pain patients a cork so that they know how wide they are actually stretching.

Beverly Hills TMJ Cork Rich Hirschinger

A cork is an excellent therapy device. It can be cut with a ramp to give the patient guidance to where they need to be stretching to help reduce their muscle pain. When the return for their follow up visit, they should be able to comfortably open the full length of the cork. If they cannot, they have not been doing their part to help themselves.

A standard cork is 45 mm and it can be cut down in case the patient cannot open that wide. In addition, the doctor needs to try to find what the patient is possibly doing to contribute to their pain. Are they clenching, and/or grinding their teeth? Are they doing an excessive amount of chewing such as using chewing gum? If they cannot stop the clenching habit on their own, I refer them to a pain psychologist who can help them identify what they are doing to contribute to their pain, and and the pain psychologist can do  some cognitive behavior therapy to help make the patients aware of the bad habits that are contributing to their chronic pain.

Ethyl chloride should be tried in the office to see what effect that has on the patient’s pain. If it is beneficial, teach the patient how to use it and write them a prescription. I prefer the bottle to the can since the bottle is colder, and, I believe, much more effective. If you ask me what one “toy” I cannot live without to help my Beverly Hills orofacial pain patients, I would answer, “ethyl chloride.”

During this time a stabilization splint should likely be made. I prefer hard, full coverage appliances. Patients tend to treat soft appliances like a gummy bear by clenching and releasing, clenching and releasing, etc., which can actually increase their pain. Additionally, a nighttime muscle relaxer such as tizanidine or cyclobenzaprine can be considered.

If those steps have not helped reduce the pain, then I recommend trigger point injections using 1% lidocaine without epinephrine. Trigger points are not simply an injection of anesthetic into the muscle so a doctor should understand how to give trigger point injections if they want to treat chronic muscle pain. Epinephrine is myotoxic to muscles and should never be injected into a muscle. It is well known that plain lidocaine only lasts from two to four hours but a trigger point injection can provide pain relief for a week or even longer. The needle is repeatedly inserted into the muscle, which is called “peppering,” and it is the action of the needle that breaks up the pain mediators such as CGRP, Substance P, glutamate and others. If the trigger point injection helps but only for a week, then repeat the trigger point injection and see how long the benefit lasts. If the second round of trigger points only lasts one week that is when I would consider using Botox.

Lastly, the research does not conclusively support the use of Botox for myofascial pain. I’m not saying that it cannot work, and I’m not saying that the pain relief that some patients report after Botox injections does not decrease their pain. What I’m saying is that Botox should be used last after you have tried everything else. I will also state that any doctor who states that they use Botox for TMJ treatment does not know what they are treating since the TM joint is not made up of muscles, and it is important to left the patient know they do not have TMJ but they have muscle pain. The TM joint is a disc. Yes, muscles attach to the joint but the superior head of the lateral pterygoid attaches to the disc, which is almost never the cause of a patient’s pain. The inferior head of the lateral pterygoid can be the cause of a patient’s pain but Botox should never be injected into the inferior head of the lateral pterygoid without electronic muscle guidance and ultrasound. If a doctor is not using guidance to inject into that muscle, there is no way to know where the Botox is actually being injected. Lastly, if a doctor does inject Botox into the superficial masseter, a short needle should not be used since the needle might not penetrate past the parotid gland.

Be safe, be careful, and use Botox last if nothing else works.

Tension-Type Cluster Paroxysmal Hemicrania Continua and SUNCT Headaches

Posted on: November 17th, 2013 by Dr. Rich Hirschinger 1 Comment

Tension-Type Headaches and TAC Headaches

In my last post, I explained how to diagnose a migraine based on the International Headache Society criteria. This post will focus on two other categories of primary headaches that I treat at my headache and chronic head and neck pain practice in Beverly Hills, CA. The two are tension type headaches, and the trigeminal autonomic cephalgias, which is a very fancy term that describes several headaches that I will explain below.

Beverly Hills near Los Angeles tension type headaches

Tension-type headaches feel like a tight band around your head.

Tension-type Headaches

Tension-type headaches are the most common type of primary headache known to man. Primary headaches are headaches without any other cause such as a tumor, a stroke, head trauma, etc. The diagnosis of a tension-type headache is based on the follow criteria:

  1. The headache lasts between 30 minutes and one week.
  2. The headahces has two of the following four criteria:
    1. bilateral location
    2. Pressing/tightening (non-pulsating) quality
    3. Mild or moderate intensity
    4. Not aggravated by routine physical activity such as walking or climbing stairs
  3. And both of the following:
    1. It can have either photophobia (light sensitivity) or phonophobia (sound sensitivity) but not both.
    2. No nausea or vomiting.

If the criteria above is met, then a diagnosis of tension-type headache is made.

Trigeminal Autonomic Cephalgias

Three are four headaches in this category. All are one-sided headaches, which have autonomic involvement. The autonomic nervous system is the type of reaction that humans cannot typically control such as heart rate, respiratory rate, digestion, salivation, perspiration, pupillary dilation, urination, and sexual arousal. When it comes to the trigeminal autonomic cephalgias, the signs that occur are eye redness, eye tearing, runny nose, droopy eyelid, nasal congestion, and forehead and facial sweating on only one side of the face.

Cluster headache Dr. Rich Hirschinger Beverly Hills

Cluster headaches occur in and around the eye on one side of the face.

Cluster Headache

The diagnosis of a cluster headache is based on the following criteria:

  1. A history of at least 5 attacks
  2. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes if untreated
  3. Headache is accompanied by at least one of the following:
    1. Same side eye redness and/or tearing
    2. Same side nasal congestion and/or stuffy nose
    3. Same side eyelid swelling
    4. Same side forehead and facial sweating
    5. Same side constriction of the pupil and/or droopy eyelid
    6. Sense of restlessness or agitation
  4. The attacks have a frequency from one every other day to eight per day.
  5. The headache is not attributed to another disorder.

Paroxysmal Hemicrania

The attacks of paroxysmal hemicrania are similar in characteristics of pain and associated symptoms and signs to those of cluster headache, but they are shorter-lasting, more frequent, occur more commonly in females and respond absolutely to indomethacin, which is a non-steroidal anti-inflammatory medication in the same class as aspirin.

The diagnosis of a paroxysmal hemicrania is based on the following criteria:

  1. At least 20 attacks fulfilling criteria 2-4
  2. The attacks of severe same side orbital, supraorbital (above the eye) or temporal pain (pain in the temples) lasting between two to thirty minutes.
  3. Headache is accompanied by at least one of the following, which must occur on the same side as the headache:
    1. Same side eye redness and/or tearing
    2. nasal congestion and/or stuffy nose
    3. eyelid swelling
    4. forehead and facial sweating
    5. constriction of the pupil and/or droopy eyelid
  4. The attacks have a frequency above 5 per day for more than half of the time although periods with lower frequency may occur
  5. The attacks are prevented completely by therapeutic doses of indomethacin.
  6. The headache is not attributed to another disorder.

SUNCT

SUNCT is an acronym that stands for “Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing.” This headache is very rare and is characterized by short-lasting attacks of same-sided pain that are much briefer than those seen in any other trigeminal autonomic cephalgias, and very often accompanied by prominent eye tearing and redness of the eye on the same side as the headache.
The diagnosis of a paroxysmal hemicrania is based on the following criteria:

  1. At least 20 attacks fulfilling criteria 2-4
  2. Attacks of unilateral orbital, supraorbital  (above the eye), or temporal stabbing or pulsating pain lasting 5-240 seconds
  3. Pain is accompanied by same side eye redness and/or tearing
  4. The attacks occur with a frequency from 3 to 200 per day.
  5. The headache is not attributed to another disorder.

Hemicrania Continua

This headache is persistent strictly one-sided headache responsive to indomethacin, which is a non-steroidal anti-inflammatory medication in the same class as aspirin.
The diagnosis of a hemicrania hemicrania is based on the following criteria:

  1. A headache for greater than 3 months fulfilling criteria 2-4
  2. All of the following characteristics:
    1. same-sided pain without changing sides
    2. daily and continuous, without pain-free periods
    3. moderate intensity, but with exacerbations of severe pain
  3. At least one of the following autonomic features occurs during exacerbations and on the same side of pain:
    1. redness and/or tearing
    2. nasal congestion and/or stuffy nose
    3. constriction of the pupil and/or droopy eyelid
  4. Complete response to therapeutic doses of indomethacin
  5. Not attributed to another disorder

Next weeks post will discuss the fourth category of primary headaches, which are the Other Primary Headaches, and the following week I will start to discuss the different ways to treat all of the primary headaches.

Respectfully,

Rich Hirschinger, DDS, MBA
Diplomate, American Board of Orofacial Pain
Member American Academy of Orofacial Pain
Lecturer, UCLA Orofacial Pain and Dental Sleep Medicine
www.LoveOFP.com
888.981.8981

Headache is Not a Diagnosis

Posted on: October 13th, 2013 by Dr. Rich Hirschinger 2 Comments

Headaches Explained by Dr. Rich Hirschinger Beverly Hills

I learned very early in the first few days of my two year orofacial pain residency at UCLA that “headache is not a diagnosis.” Every time I make a diagnosis of a type of headache it is based on the criteria of the International Headache Society. This post will help you  understand what type of headache you might have and will focus primarily on migraines.

It is very important to understand the difference between a primary headache, and a secondary headache. A primary headache is a headache that is not attributed to another disorder. A secondary headache is a headache that is attributed to another disorder such as a tumor, a stroke, a brain bleed, etc. In other words, there is nothing else causing a primary headache whereas a secondary headache is caused by something else.

I use several acronyms to remember the various types of headaches, some of which I learned from others and a few that I created myself. One of the acronyms I learned from others is SNOOPS. These are the “red flag” signs of headaches that require immediate attention.

S stands for systemic, which include symptoms such as a fever, and weight loss.
N stands for neurological, which includes symptoms such as confusion, altered level of consciousness, or numbness.
O stands for onset such as a very sudden, abrupt, split second onset of the headache.
O stands for older. If you are older than approximately 50 years of age, and the headache is a new onset or progressive, that is a red flag.
P stands for previous history of headaches. If you have a previous history of a headache but this headache is new or different, if there is a change in attack frequency, severity or clinical features then that is a red flag.
S stands for secondary risk factors. If you have a systemic condition such as HIV, or systemic cancer along with the headache that is a red flag.

If you have any of these red flags, immediate attention in an emergency room is the best course of action.

Primary Headaches

There are four categories of primary headaches, which are:

  1. Migraine
  2. Tension-type headaches
  3. Cluster headache and other trigeminal autonomic cephalalgias
  4. Other primary headaches

Migraine

Beverly HIlls Migraine Headaches

Over 60% of migraines are unilateral

There are many types of migraine headaches but the main type of migraine headache is easy to diagnose based on the International Headache Society criteria. The acronym I created to remember the criteria is 5472 PUMA PPNV ACE. Let me explain how to interpret the acronym so that it makes sense.

Many people think that since they have a headache it is a migraine. This could not be further from the truth. Just like headache is a not a diagnosis, if you have a headache, it does not necessarily mean you have migraines. If you meet the following criteria, then you have a migraine.

Migraine Criteria 5472 PUMA PPNV ACE

5472 – If you have had 5 headaches in your life lasting between 4 and 72 hours that was untreated or did not respond to treatment, then move to the next set of criteria to see if you have a migraine headache.

PUMA – If you have two of the four PUMA criteria during the headache, then move to the next criteria to see if you have a migraine headache.

  1. P stands for pulsating, throbbing type of headache.
  2. U stands for unilateral. Over 60% of migraines are unilateral, which means a one sided headache.
  3. M stands for moderate to severe.
  4. A stands for aggravation with exertion meaning the headache gets worse if you walk, run, work out or exert yourself.

PPNV – If you have one of the following criteria during the headache, including the above criteria, then you have met the diagnosis of a migraine.

  1. Photophobia and phonophobia. Photophobia means that the headache causes you to be sensitive to light, and phonophobia means that the headache causes you to be sensitive to sound.
  2. Nausea and/or vomiting.

ACE – If the criteria for migraine has been met then ask if there is an aura, and how frequent the migraine headaches occur.

A stands for aura. Aura’s can be positive or negative, and they can be visual or sensory, and the symptoms are completely reversible.
C stands for chronic. If you get 15 or more migraines a month, it is a chronic migraine.
E stands for episodic. If you get less than 15 migraines a month, it is an episodic migraine.

Aura – An aura gradually develops over a period of about 5-20 minutes and lasts for less than an hour.The aura can be fully reversible visual symptoms like lines, spots, or beautiful colors, which are all positive auras meaning you see something extra, or holes in the visual field called scotomas, or gray spots, which are all negative auras meaning you see something less than you usually see. The aura can also be fully reversible sensory symptoms such as like pins and needles, or numbness, which is a positive aura, or slurred speech, which is a negative aura.

Based on the above criteria, you should be able to know if you truly suffer from migraines. In the next post, I will discuss how to treat migraines, which is based on both abortive treatments, meaning how to treat the migraine after it starts, and preventative treatments, meaning how to help prevent migraines from occurring.

Quick Migraine Symptom Diagnosis

Having stated all of the above, research shows a very simple way to determine if you have a migraine by answering the following questions.

  1. Has the headache limited your activities for a day or more in the last three months?
  2. Are you nauseated or sick to your stomach when you have a headache?
  3. Does light bother you when you have a headache?

Patients who answer positively to two out of these three symptom questions have a 93% chance of a migraine diagnosis and, if all three are answered positively, a 98% chance of a migraine diagnosis. If think you have a migraine, or if you know you have migraines but the previous treatments have not been helpful, you can request an appointment at my Beverly Hills migraine headache office. As always, I’m happy to try to answer any questions you might have.

Respectfully,

Rich Hirschinger, DDS, MBA
Diplomate, American Board of Orofacial Pain
Member American Academy of Orofacial Pain
Lecturer, UCLA Orofacial Pain and Dental Sleep Medicine
www.LoveOFP.com
888.981.8981

What is OFP – Orofacial Pain

Posted on: October 6th, 2013 by Dr. Rich Hirschinger 4 Comments

What is Orofacial Pain?

OFP, which stands for orofacial pain, is a unique branch of dentistry practiced by Dr. Rich Hirschinger at his office in Beverly Hills, California that involves the diagnosis, and management of chronic head and neck pain using very conservative treatment methods. The types of conditions that OFP doctors treat include primary headaches such as episodic or chronic migraines, tension-type headaches, and cluster headaches, myofascial pain, which is a fancy way of saying pain caused by muscles, neuropathic pain such as trigeminal neuralgia, which is pain caused by damage or irritation of a nerve, TMJ, which stands for temporomandibular joint, and obstructive sleep apnea. What OFP does not involve is the treatment of teeth since evidenced-based research shows that chronic head and neck pain is not related to the occlusion, which is how the teeth come together.

Beverly Hills TMJ Migraine Heacaches

Woman suffering from chronic head and neck pain

There are dentists who practice what they call neuromuscular dentistry, which is not taught in any accredited dental school in the United States, who argue that a lot of the chronic pain patients report is caused by the “bite.” They claim that teeth touch about 2,000 times a day when we swallow, and when we chew food. I agree teeth touch when we swallow but it is a light touch that does not involve a full contraction of the muscles that close the jaw and cause the teeth to meet, and teeth rarely touch when chewing since there is food between the teeth. Additionally, we should not walk around with our teeth clenched during the day so we teach patients the “n rest position” so that addresses the issue of any daytime pain being caused by how teeth meet. Both OFP doctors and neuromuscular dentists agree that patients clench and/or grind their teeth at night but this can be addressed by covering the teeth at night with a nightguard, which should be a hard appliance that covers all of the teeth, is not designed to change the bite, and it only worn at night. This addresses the issue of any nighttime chronic pain being caused by how teeth meet since the teeth contact the appliance instead of other teeth. Lastly, Dr. Hirschinger and most orofacial pain colleagues do not use a dental drill to alter or adjust the teeth. That begs the question that if OFP doctors can treat patients with chronic head and neck pain without touching or drilling teeth, why wouldn’t every doctor try treating patients using the same conservative, reversible procedures before trying any other approach?

The goal of this blog will be to educate doctors as well as the public about orofacial pain by discussing the treatment approach I use as well as posting some very interesting cases. Since very few doctors are aware of OFP, very few patients are aware of it. However, orofacial pain is getting more recognition because starting in 2011, the Commission on Dental Accreditation of the American Dental Association has accredited ten post graduate programs in orofacial pain. The first two in 2011 were UCLA, where orofacial pain was founded by Dr. James Fricton, and Kentucky. Dr. Hirschinger was the first graduate from UCLA’s Orofacial Pain and Dental Sleep Medicine residency after it received CODA recognition.

The key part of treating anyone with chronic pain is getting a diagnosis before treatment is started. For the patients I see, headache and TMJ are not considered enough of a diagnosis to initiate treatment. What type of headache is it, and what is causing the pain? If your doctor does not know, then I would suggest that you find someone who can give you a diagnosis.

Please spread the word about this blog by telling your colleagues and friends to sign up to receive notifications of new posts. I look forward to answering any questions you have about any chronic head and neck pain you are personally experiencing, or if you have a question about a patient of yours.

Rich Hirschinger, DDS, MBA
Diplomate, American Board of Orofacial Pain
Member American Academy of Orofacial Pain
Lecturer, UCLA Orofacial Pain and Dental Sleep Medicine
www.LoveOFP.com
888.981.8981