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 ‘Dr. Rich Hirschinger’

TMJ Muscle Range of Motion Measurements

Posted on: June 27th, 2017 by Dr. Rich Hirschinger 2 Comments

The notch fits into the midline of the lower central incisors.

TMJ Muscle Range of Motion Measurements
A patient’s range of motion measurements should be recorded as part of every new patient exam. This adds anywhere from 20 seconds to a new patient exam if you only record the three opening movements, which are “comfort, active, and passive.” If you measure right and left lateral and protrusive movements, you might be adding 60 seconds to your exam time. Yes, it’s that quick.

Normal Range of Motion
Opening: 40 to 60 mm. If a patient opens to 55 mm with either the comfort or active opening, there is no need to obtain the Passive opening. Additionally, do not have a patient open past 60 mm and do not push a patient open past 60 mm. If they can open to 60 mm or you can push them to 60 mm, then they have an excellent opening range of motion.
Lateral: 8 to 12 mm
Protrusive: 8 to 12 mm

Opening MovementsHirschinger TMJ Beverly Hills Range of Motion
Place the notch of the range of motion scale on the midline of the mandibular centrals, and take the following three measurements:
Comfort: ask the patient to open “comfortably without pain.”
Active: ask the patient to open as wide as they can even if it hurts.
Passive: with the patient in the Active opening, the doctor then pushes the patient open using their thumb on the maxillary centrals and the index or middle finger on the mandibular centrals.

Lateral Movements
With the arrow of the range of motion scale centered on the maxillary centrals, have the patient move to the left by tapping the mandible on the left, which causes the patient to move to the side that you are tapping. Measure the distance traveled. Repeat this for the right side by tapping the right side of the jaw.


Protrusive Movement
Fold the range of motion scale in half at the black triangle on the lateral scale. Measure the overjet, then ask the patient to move their jaw forward “like a bulldog” and measure that number. Record those two numbers as separate numbers such as “2+8” so that you know the overjet plus how far they can protrude forward from their centric occlusion.

Note in your chart if any of the movements cause pain and if any of the movements replicate their jaw pain. If a movement does cause pain, have the patient point with one finger where the pain occurs.

If the patient ever has a future problem with opening and/or moving their jaw, you now have a baseline of what their normal movements are. Do you think it is worth spending up to one additional minute of your time to record these measurements? You will if you ever have a patient who has a problem especially if they think you created it with an injection or by keeping them open too long.

As always, I’m happy to help any patient who is experiencing jaw pain or any facial pain including migraines, trigeminal neuralgia, sleep apnea or snoring issues at my office in Beverly Hills. Please let me know how I can help or if you have any questions.

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


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.


Rich Hirschinger, DDS, MBA
Diplomate, American Board of Orofacial Pain
Member American Academy of Orofacial Pain
Lecturer, UCLA Orofacial Pain and Dental Sleep Medicine

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