A step in the right direction: Failures in facial pain and the importance of the first step

I will start this article with a unique and powerful statement that resonated with me while I was teaching in the Graduate Studies Program at the University of Toronto School of Dentistry. The TMD course coordinator, Dr. Iacopo Cioffi, made a very bold statement: “Regardless of the therapy provider, it is important to know that the therapy being provided is proper and the standardization of care has proven to be successful, conservative, and safe for the patient.”

I cannot tell you how many times a patient visits our office in pain, having seen no less than five to seven different doctors or therapists of varying professions with no success. Most of these patients (with respect to my niche practice of facial pain) have not had the same opinion twice, have not had the same therapy suggested twice, and have not had the correct therapy done for their condition.

I recently finished with a patient that had a high level of genetic hypermobility. The patient was seen by a dentist, who diagnosed the patient with temporomandibular disorder (TMD) and subsequently referred her to a physiotherapist. The physiotherapist assessed the individual, without having the background to diagnose appropriately or to review the umbrella diagnosis of TMD. The therapy consisted of one hour of soft tissue therapy and ultrasound for a period of five weeks, one time per week. The muscular pain decreased, and the temporomandibular joint pain (TMJ) increased. The patient returned to the dentist at which point a re-positioning splint was made to position the mandibular condyles anterior in the joint to offload the joints and relax the muscles. From my experience, these splints may help in the short term with pain, but in the long term do more harm. (One can reference this at tmj.org for further validation.)   After stopping the physiotherapy, the pain returned. After six months of wearing the splint, the pain increased, and she now had an open bite from spasm and early impacting of her molars in a closed mouth position.

The dentist referred her to an oral surgeon to now correct the open bite. This amazing oral surgeon diagnosed the patient with capsulitis or chronic joint inflammation due to TMJ hypermobility. She was told to stop wearing the night guard and was referred to the Jaw & Facial Pain Centre. She did not comply with the referral.

At the same time, the patient consulted with her family physician who told her to try anti-inflammatories and muscle relaxants which they prescribed. These helped her when she was taking them, but once the courses of medications finished her pain returned. The medications did not effect  the open bite and as time went on, the pain increased.

Her family physician subsequently referred her to a neurologist and was prescribed aggressive pain medication which temporarily helped, but over the coming months, the patient had to increase the medication dosage to a point where they could no longer tolerate the dose and the effect it was having on them. The new medications did not effect the open bite. The neurologist referred the patient to a different oral surgeon. The new oral surgeon recommended an aggressive surgery to close the open bite, but did note, he was not sure it would relieve the pain. The alarm bells started sounding and she returned to the first oral surgeon who once again told her she had capsulitis or chronic joint inflammation due to TMJ hypermobility and referred her to the Jaw & Facial Pain Centre.

After nine weeks of CONSERVATIVE therapy using a progressive loading model for instability, the patient reported 70 to 80% improvement in pain and an 80 to 90% improvement in function. Her open bite began to close, with a timeline of 12 months for return to normal explained.  Appropriate referrals to an orthodontist with advanced training in facial pain were made to confirm the timeline.

These types of cases are all too common in our office, many times with major interventions being suggested or already provided. The first lesson here is CONSERVATIVE first unless something ominous clearly presents itself. The second lesson is that if you get the first step wrong, the probability of getting the next step right with respect to that specific patient decreases markedly. Then the errors will just compound as their care moves forward.

New practitioners at our centre would hear me call this the inverted triangle of unnecessary escalation. In effect, not only do we fail to treat the patient’s primary complaint, but because we take so long to help the patient with their pain, we allow changes in the brain to occur which subsequently creates secondary complaints, multiple co-morbidities and inevitably “pain patients.” During my time at a special interest practice with oral and facial pain I have had the opportunity to work with some very excellent professionals. One that stands out is Dr. Demetry Assimakopoulos, a chiropractor, who like me, has a niche practice that is focused on chronic pain. We would have many discussions about my “inverse triangle patients.” He has since educated me that my “inverse triangles” should be re-classified as “Failures in Stepped Care.” This patient is certainly one of them. Luckily the oral surgeon and our team were able to walk her back “down the steps” and find a conservative solution so that she could avoid an unnecessary surgical intervention and all the complications that can come with it. We see these types of patients all too frequently, at a rate of almost four to five new per week.

It is an uphill battle to correct failures in stepped care. I have started to see a paradigm shift. First, we are starting to see more special interest practices with those with advanced training for certain parts of the body. Second, we are starting to see practitioners accept that the conservative box MUST be ticked first. In fact, it must be ticked a second time by someone with more advanced training with respect to that patient prior to more aggressive therapies being attempted, unless something ominous presents itself. Third, we are seeing an increase in allied health collaboration before more invasive approaches being considered. (I would certainly credit the team at the Craniofacial pain clinic at Mount Sinai as leaders in this concept with oral and facial pain.) Fourth, practitioners are becoming confident and firm in stopping patients from “climbing the steps” and noting that they are a large part of their health care journey. I will not refer a patient up the step until they have shown they can be 100% compliant with care. This is often difficult while remaining patient-centric. Fifth, we are gaining a better understanding of what that first step looks like. It is not just the therapy we give to the patient but looking at the patient as a whole person. So, in effect, we treat the patient’s problem, we acknowledge the comorbidities and other injuries that may affect their pain interpretation and excitability. We accept that there is a somatic, psychological, neurologic, environmental, and sometimes genetic component to their pain. Lastly, we all need to know to check our egos at the door. We are not going to succeed with every patient, we need to understand that this might not be a patient that we can help and sometimes know that the best care is not in our office for that condition.

I’m going to leave you with a statement from a patient who is a prime example of the far-reaching effects of failures in stepped care. What started with a simple click in her jaw ended up in total joint replacement. We need to watch that “first step” – it has profound ramifications in our patients’ lives!

“TMD has affected every aspect of my life: physically, emotionally, financially, psychologically, professionally, and it has affected my relationships, my passions, my independence, and at times my dignity. It cut me off at the knees and changed the landscape of my life, and what I imagined my life would be. I have had to accept that, we’ve all had no choice but to accept that.” 

DR. SIDNEY LISSER is a chiropractor with a special interest practice in jaw and facial pain. He is the Clinic Director of The Jaw and Facial Pain Centre in Toronto, ON.