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
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Posts Tagged ‘chronic pain’

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.

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