What Your Dentist Should Know About FMS and CMP
Trigger Points and Dentistry
Both fibromyalgia syndrome (FMS) and chronic myofascial pain (CMP) can have a large
impact on dental care. It is essential for you to know that your patient may have
various muscles constricted by myofascial trigger points (TrPs) in such a manner as
to change the occlusion, forcing the mandible to close unnaturally (Fricton 1995). When
the TrPs have been treated, occlusal contacts will change (Abdel-Fattah 1997). This can
be a disaster if you have equilibrated the occlusion to the contraction of the muscles
(Shankland 1996; Abdel-Fattah 1997). Trigger points can be caused by malocclusion, and
the reverse is also true.
Equilibration and TrP treatment must take place together or they may be ineffective.
Some clinicians and researchers (Abdel-Fattah 1998) believe that degrading of articular
discs and bony structures of the temporomandibular joint can result. Patients with FMS
and/or CMP may react in unusual ways to bite splints. Sometimes splinting makes things
worse. Some patients have bitten through a splint in one night. Often processed,
reinforced splints are required. In addition, a medication may also be required at
bedtime for the severe bruxers (Shankland 1983). For those with the combination of
bruxism, muscle twitches, and cramping, clonazepam may be helpful.
Teeth clenching is a default mechanism of the brain. When it doesn't know what to do to
respond to mixed or erratic signals, it may clench the jaw, a sort of twiddling of the
cranial thumbs. Look for masseter TrPs and temporalis TrPs. Problems swallowing, chewing
pain, jaw clicking, TMJ symptoms, soreness inside the throat, excessive saliva secretion
and sinusitis-like pain, drooling during sleep, and choking on saliva can all result
from an internal medial pterygoid TrP, which is often overlooked.
Trigger Points and Toothaches
Unexplained toothaches can be caused by several TrPs, chiefly in the temporalis,
digastric, and masseter muscles. Each TrP has its own particular toothache pattern. Any
kind of immobility can activate TrPs. Usually, a TrP-induced toothache is intermittent.
During long dental procedures, take periodic rests to allow your patient to exercise and
relieve the jaw muscles. Find out what symptoms go along with each TrP. For example,
anterior digastric TrPs refer pain to the two front lower teeth, and the resulting tooth
pain is often mistaken for pulpitis. Unfortunately, many unnecessary endodontic
procedures are performed in an attempt to treat the patient's tooth pain, only to have
the pain continue after the pulp of the tooth is gone. Anterior TrPs may also cause
difficulty swallowing. Ask your patient about localized pain elsewhere in the body. See
if you can't find a pattern. If there is inexplicable dental pain, dysfunction, and
sensitivity, suspect TrPs. Pain can be referred to teeth from various TrPs in the upper
Sternocleidomastoid (SCM) TrPs
The SCM TrPs are responsible for many motor coordination problems. They can cause:
- neck soreness
- swollen gland feeling
- runny nose
- maxillary sinus congestion
- "tension" headaches
- eye problems (tearing, blurred or double vision, inability to raise the upper lid,
and a dimming of perceived light intensity)
- spatial disorientation
- postural dizziness
- sudden falls when bending
- staggering walk
- impaired sleep
- nerve impingement
- and disturbed weight perception
Primary TrPs in the SCM often cause secondary TrPs that invoke dental pain. With SCM
TrPs, it's quite common for a TrP to develop in the opposite lateral pterygoid muscle,
producing malocculsion and perpetuating the TMJ/TrP cycle of pain and dysfunction.
People with SCM TrPs often have trouble glancing downward - they become so disoriented
that nausea and vomiting result. Chronic dry cough, pain deep in the ear canal, pain to
the throat and back of the tongue and to a small round area at the tip of the chin can
be part of the SCM TrP package. Localized sweating and vasoconstriction can be a
problem, as well as pain in a "skull cap" area of the head. These TrPs can also cause
pain at the mastoid process and the deep nuchal line.
Almost all patients with both FMS and CMP have "vasomotor rhinitis" at least some of
the time. That's a runny nose with no "biological" cause. Normal fluid passages may
be constricted, so there can be a constant postnasal drip all night, although the
membranes of the nose may feel very dry and even bleed.
One cause of prickling "electric" face pain over the jaw area is from compression of
the buccal nerve by the two parts of the lateral pterygoid muscle in chronic bruxers.
This sensation is frequently experienced upon waking in the morning or during times of
intense stress. This symptom may also be caused by platysma TrPs. Jaw pain and
dysfunction are often the fault of one or more masseter TrPs, although trapezius and
temporalis TrPs are often involved. Cutaneous facial TrPs can cause pain in the ears,
eyes, nose, and teeth. These TrPs are shallow, and can occur in many places on the face.
Jaw pain and dysfunction are often the fault of one or more masseter TrPs, although
trapezius and temporalis TrPs are often involved as well. Tell your patients to try
acupressure. It may be vital to find a trained trigger point myotherapist to work with
you and your patients (Heinrich 1991).
Trigger Points Caused by Prophylaxis
Because FMS is a pain amplification syndrome, even routine prophylaxis can be severely
painful for patients with both of these conditions. In FMS, some of the mechanoreceptors
have become pain receptors, and central nervous system plasticity plays a large part in
amplifying all pain (Russell 1996; Yunus 1992; Bendtsen, Norregard, Jensen, et al. 1997;
Lautenbacher and Rollman 1997). Tense muscles from the pain of cleaning may cause the
jaw to hurt for more than a week. You might use infiltration of local anesthetic into
the gingiva, where most of the scaling is necessary. It's also helpful if there are
frequent stops to move the jaw during cleaning and other dental work. Prescribe a muscle
relaxer, such as Skelaxin, before and after cleanings, to allow for more stretching of
the jaw. Your patients can experience pain even during X-ray; those squares cut right
in, especially under the tongue. Have the patient work on the masseter muscle for the
next few days, using moist heat and acupressure. Note that many FMS patients cannot
tolerate epinephrine in the local anesthetic. Recent research shows that norepinephrine
can provoke FMS pain (Martinez Lavin, Vidal, Barbosa et al 2002).
Root canals can be torture. FMS patients feel pain earlier in the case of a threatened
nerve and feel extreme pain longer, often when other patients would feel none at all
(Staud, Smitherson 2002). Sometimes it is impossible to eliminate all of the pain. It is
vitally important to get all the pulpal tissue out of the tooth as quickly as possible,
again allowing the patient frequent rest periods. Patients have reported cases of
"myofascial neuralgia" after a root canal, with pain that lasted a month or more.
People with these conditions have more than the usual difficulty adjusting to dentures,
probably due to the FMS amplification of pain and the alteration in function of the
muscles of mastication while chewing, especially with complete dentures. It is
important that dental problems be fixed promptly. Dentures must fit, and any imbalances
in the occlusion must be corrected, particularly when the patient is relaxed and
his/her muscles are not painful. You may have to perform a re-mount procedure when
attempting to refine the occlusion. Trigger points on both sides should be treated
because of the interrelation of the musculature and jaw structures.
For the TMJ patient after a dental appointment, applying ice followed by moist heat on
the masseter and temporalis TrPs a few times a day may ease the pain. Tell your patient
to avoid chewing gum and hard chewy foods, to limit mouth opening, and to chew foods
as evenly as possible on both sides of the mouth. Instruct patients to brace their chin
and limit mouth opening, even when yawning. Spray and Stretch with vapocoolant to
inactivate TrPs is described in detail in the Travell and Simon's Trigger Point Manual,
Volume I (Simons, Travell and Simons, 1999). You might even demonstrate Spray and Stretch
to the patient's spouse or companion. Ischemic compression using acupressure techniques
is also often effective. Prescribing an anti-inflammatory medication the day before,
the day of, and the day after the dental appointment can be very helpful. Also, consider
prescribing a mild muscle relaxant as well. First discuss current medications. With FMS
and CMP, medications may change frequently. If you cannot specifically identify the cause
of tooth pain or any other facial pain complaint, do no harm! Don't initiate any
irreversible procedure such as endodontic therapy, oral surgery, or equilibration. Also,
don't assume the diagnosis is cracked tooth syndrome just because the patient complains
of tooth pain from an unknown origin.
- Abdel-Fattah, R. A. 1998. Craniomandibular Myofascial Pain: Diagnosis and Treatment.
Lecture: Travell Focus on Pain Seminar, San Antonio, TX, March 12B15.
- 1997. An introduction to occlusal biomechanics in temporomandibular disorder.
- Bendtsen, L., J. Norregaard, R. Jensen and J. Olesen. 1997. Evidence of
qualitatively altered nociception in patients with fibromyalgia. Arth Rheum
- Fricton, J. R. 1995. Management of masticatory myofascial pain. Semin Orthod
- Heinrich, S. 1991. The role of physical therapy in craniofacial pain disorders:
an adjunct to dental pain management. Cranio 9(1):71-75.
- Lautenbacher, S. and G. B. Rollman. 1997. Possible deficiencies of pain modulation
in fibromyalgia. Clin J Pain 13(3):189-196.
- Martinez-Lavin M., M. Vidal, R. E. Barbosa et al. 2002. Norepinephrine-evoked pain
in fibromyalgia. A randomized pilot study [ISRCTN70707830]. BMC Musculoskel Disord
- Russell, I. J. 1996. Neurochemical pathogenesis of fibromyalgia syndrome. 1996. J
Musculoskel Pain 4(1/2):61-92.
- Shankland II, W. 1996. TMJ: Its Many Faces. Columbus: Anadem Publishers.
- 1983. Craniomandibular pain: current treatment options. Ohio Dent 57(7):53-57.
- Simons D. G., J. G. Travell, and L. S. Simons. 1999. Travell and Simons' Myofascial
Pain and Dysfunction: the Trigger Point Manual: Volume I, edition 2: The Upper Body.
Baltimore: Williams and Wilkins
- Staud, R., S. M. Smitherman. 2002.
- Yunus, M. B. 1992. Towards a model of pathophysiology of fibromyalgia: Aberrant
central pain mechanisms with peripheral modulation. J Rheumatol 19:6:846-850.