Ignoring jaw pain comes at too high a price [PODCAST]

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“The COVID-19 pandemic challenged health care systems and patients’ personal economic capacity, leading to approximately six million adults losing their dental insurance. Additionally, the World Health Organization and the American Dental Association recommended dentists to limit their practices to emergency and urgent dental care.

In the list of these diagnoses requiring emergency care, jaw pain (temporomandibular disorder (TMD) that includes several clinical problems involving the temporomandibular joint and group of muscles that help with chewing and other associated structures), was not included.

This is not acceptable.”

Soumya Padala is a craniofacial orthodontist.

She shares her story and discusses her KevinMD article, “Delta surge warning: Ignoring jaw pain comes at too high a price.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Soumya Padala. She is a craniofacial orthodontist, and she wrote the KevinMD article “Delta surge warning: Ignoring jaw pain comes at too high a price.” Soumya, welcome to the show.

Soumya Padala: Thank you. Thank you, Kevin, for this opportunity.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Soumya Padala: I’m originally an orthodontist from India, and then I moved to the United States to complete my internship and fellowships. Then I had to complete an orthodontic residency in order to be board-certified here, and then later, at Rush Medical Center, I received the craniofacial training. Now I’m a craniofacial orthodontist.

Kevin Pho: So we don’t get very many craniofacial orthodontists on this podcast. Tell me a little bit about what you do and some of the common cases that you see.

Soumya Padala: Craniofacial orthodontics is actually another additional layer of specialty over the orthodontic training that we receive during our residency. As a craniofacial orthodontist, we work with the surgeons in order to treat patients who are born with cleft and craniofacial deformities. Additionally, we assist the surgeon with the oral rehabilitation of patients who have undergone severe trauma, major trauma, and also in the gender affirmation clinic, we assist them when they’re doing the facial gender procedures. So in all of those procedures, we assist the surgeons in trying to establish the facial and the dentofacial structures.

Kevin Pho: All right. So tell me some of the challenges that you face typically every day as a craniofacial orthodontist.

Soumya Padala: I think the challenges are because it’s not a routine orthodontic patient who comes in for just changing wires or aligners. These patients need more attention, and also developing a treatment plan for this patient requires me to speak to 10 other providers of this patient in order to develop a good, comprehensive, multidisciplinary plan. It’s not just me making the decision. My treatment plan relies on all the other providers.

Kevin Pho: Let’s go ahead and talk about the KevinMD article that you wrote, and I’m interested in hearing about how COVID is affecting your field. It’s titled “Delta surge warning: Ignoring jaw pain comes at too high a price.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Soumya Padala: The reason I was interested in writing this article is, as a craniofacial orthodontist, I’m housed inside a plastic surgery facial center, where many patients report to the clinic with facial pain or jaw pain. Then the surgeon makes the diagnosis, and if they need some sort of a splint, like an occlusal orthotic appliance, then they get referred to me. The thing is, I’ve never been exposed to as many patients with TMD disorders as I am actually seeing now in the clinic, in our practice. What I have noticed is the number of patients has increased by leaps and bounds who are reporting to the clinic, to our practice, with more facial pain and jaw pain.

The reason, I think, and what I’m seeing, is because of the stress. The levels of stress and anxiety have increased during COVID, and that leads to all these parafunctional habits, which are causing the hyperactivity of these masticating muscles, which indirectly is affecting the joint also. So there are a lot of issues, complexities developing because of these hyperactive muscles.

Kevin Pho: So tell me what some of the treatment options are when a patient comes to you where you suspect them of having a temporomandibular disorder because of stress.

Soumya Padala: When a patient comes in, it’s very important to differentiate whether this problem is a muscle-related problem or whether it’s really because of a damaged joint. We have to find out what’s the primary cause of pain. Once we delineate, OK, this is primarily a muscle issue, and then secondarily they have developed a temporomandibular joint issue, the management is different. Whereas if somebody comes in with a joint issue, and then secondarily they have developed a muscle issue, because of protective muscle co-contractions and all of that, then the management is different.

Usually, if it’s more of a muscle-related issue, then an orthotic splint will work, or maybe sometimes, just for the muscle relaxation, these stabilization splints will work. Of course, there are other splints if there is a disc issue, where the joint disc has slipped. There are some splints that help with that. But mostly the patients who need these kinds of stabilization splints are the ones with more muscle-related issues.

And the reason why diagnosis of these patients becomes more important: Somebody may have pain in the trapezius, but that pain is being referred to the jaw. So imagine I could do everything for the jaw pain; that’s not going to take away their pain, because the source of pain is here, not here. So that is where diagnosis becomes such an important key, and working as a part of the team in order to provide all these different treatments. If it’s a muscle issue or if it’s something to do with the trapezius, then we have to send them to physical therapy. Or sometimes there’s some problem with the spine, so then a spine specialist has to take a look at them. Or sometimes there’s neuralgia, occipital neuralgia or other types of facial neuralgias, which are causing this pain, when a neurologist has to step in and manage them. The causes are numerous, and sometimes they are interlaced, so in order to manage them, it takes a team.

Kevin Pho: Now, what are some of the diagnostic studies that you would do to separate a muscle cause from a joint cause?

Soumya Padala: That’s a very good question, because I feel that many people are not doing these kinds of diagnostic tests. I had mentioned in my article that most of these patients are not diagnosed correctly. They’re being underdiagnosed or actually not even being correctly diagnosed, so there’s a lot of misdiagnosis. Sometimes it’s as simple as giving a local anesthetic block. Like I said, an example is the patient who comes with the problem in the trapezius, who’s having severe jaw pain, and all the masticating muscles are hurting. I could think, “Oh, maybe I’ll just give a splint, and it’s going to work.” But then how do we diagnose? These diagnostic blocks, which are called diagnostic blocks, are local anesthetic blocks, which you inject in different muscle groups to find out which is the cause of pain. And sometimes, if it’s a TMJ pain exclusively, all you have to do is an auriculotemporal nerve block, and if that takes the pain away, then it’s a TM joint issue and not as much a muscle-related issue.

Kevin Pho: And who do you normally refer people to for these diagnostic blocks? Would it be a maxillofacial surgeon, or would it be a craniofacial orthodontist like yourself?

Soumya Padala: Usually I work with the surgeon. The oral and maxillofacial surgeon or the craniofacial plastic surgeon that I work with, they both are able to do these diagnostic blocks, and some dentists are also able to do it. But usually our patients go to these two surgeons, an oral and maxillofacial surgeon or a craniofacial plastic surgeon, to get these diagnostic blocks, and of course the other imaging, like CBCT and MRI, and a good clinical examination and a history. That is what we put together, and we are able to develop a plan for these patients and diagnose in the first place.

Kevin Pho: I’m a primary care physician. What kind of typical symptoms would I see in a primary care setting that may lead me to consider referral to a maxillofacial surgeon?

Soumya Padala: I would say if anybody gives you a history of saying, “I clench my teeth. I grind my teeth.” And then some other person may say, “I just have pain here, here, and all these areas.” And then the most important thing is function, limitation in function. They say, “I can’t open my mouth. It has reduced. It’s been progressively reducing.” And then actually, if a primary care physician is able to go in and palpate those muscles, like the pterygoids, they’ll be sore. So there are many things like this. If you see that they’re having limitation of mouth opening and they’re complaining of pain, they should be sent.

Kevin Pho: You mentioned a few times orthodontic splints. I’m actually not too familiar with those. So what exactly are they, and what would the experience be like for a patient who wears one?

Soumya Padala: So I make stabilization splints, which are also called muscle relaxation splints. What it does is, many patients probably have a bad bite, or sometimes it’s just the stimulus that comes in from the bite. You see your upper and lower teeth, the way they lock. They lock into a position. So what happens is the jaw is being moved by a group of muscles into position, right? But the occlusion of the teeth is also guiding the joint into position. So sometimes what happens is there is a big discrepancy between this occlusion and the muscle position. So imagine the jaw is constantly trying to fight where the muscles are trying to take it or where the bite is trying to take it.

And also, these kinds of splints just allow them to keep their mouth open slightly and not just clench all the time. It just allows them to keep their mouth open. So it’s just like a piece of acrylic, like those denture materials that you use to fabricate, that goes between the teeth. But it is just not like a night guard that goes in. We actually adjust it in order to replicate a very ideal natural occlusion, which will just allow the muscles to glide the jaw wherever the muscles are in their relaxed position, without having to fight the bite in order to get it into a good position. So it just neutralizes the occlusion. It basically removes the teeth out of the equation and allows the muscles to glide into that position.

Kevin Pho: We’re talking to Soumya Padala. She is a craniofacial orthodontist, and she wrote the KevinMD article “Delta surge warning: Ignoring jaw pain comes at too high a price.” Like I said, I am a primary care physician. What are some common symptoms that I should be looking out for, and do you have any tips and tricks that maybe I can apply in a primary care setting without sending patients to maxillofacial or to a craniofacial orthodontist like yourself?

Soumya Padala: I think the role of the primary care physician in diagnosing these patients is key, and giving them appropriate referrals, to know whether this patient should be sent to a neurologist first, or just sent to an orthodontist, or just sent to a team if it’s more complex. Like I said, those tests: There is a very good chapter in Jeffrey Okeson’s textbook on temporomandibular disorders, and in the 11th chapter, he discusses very nicely the symptoms and diagnosis of these patients. That’s the chapter that I believe every primary care physician should read, because these are simple examination tests. They don’t have to actually be. That’s something where you can just ask the patient to fill out the questionnaire and just do it. It will take 10 minutes to complete this exam, and then they’ll be able to diagnose and give them appropriate referrals. Of course, a complete diagnosis will not be possible until all the tests are conducted, but at least you’ll be able to gauge whether it’s a muscular issue, or is it a joint issue, or there’s something else, more complex, going on.

So as simple as, if you ask them to. There are many tests; due to the limitation of time, I’m not able to review them, but that chapter comprehensively discusses it. But as simple as opening the mouth and closing, and then, when they open and close, are they deviating? And then, when they are opening and closing, is there clicking and popping? And then I would say palpate these muscles and see. So this is the temporalis, the masseter, inside the mouth, and then the anterior neck, the posterior neck. So if you can just examine these and see the limitation in function, and also be able to see what the pain levels are, that is something that will be helpful.

And also, the key point is when there is a local provocation of the area which is the source of pain, it will intensify the pain. So for example, if somebody has a TMJ issue, if I press in that area, the pain will increase. But if it’s not a TMJ issue, it’s just the whole face hurting. So local provocation of the pain source will aggravate the pain, but the pain site will not. All this could be a pain site, but if this is the source of pain, pressing that area, the pain will increase. So again, going back to the example that we had, the trapezius muscle causing pain, like pain all over the preauricular area: If I press here, the pain is not going to intensify, but when I press on that trigger point on the trapezius, the pain will intensify. So these small clinical tips and tricks would help a primary care physician diagnose these cases better, or at least diagnose and refer in time. And also the chapter that I mentioned, in Jeffrey Okeson’s textbook on temporomandibular disorders: That book is filled with tips and tricks to diagnose these cases.

Kevin Pho: My final question: What’s your take-home message that you want to leave with the KevinMD audience?

Soumya Padala: These patients are going through a lot of pain, and nobody’s ever able to give them the effective analgesic effect that they want, to get rid of this pain. So what I want is that there should be more interdisciplinary, multidisciplinary clinics, where all the specialists come together and see these patients at the same time and give them a comprehensive diagnosis. There are people who go up to 43 or 53 providers trying to find an effective remedy for this, and some are even thinking of committing suicide. So it’s like, you don’t want these people’s lives, honestly, being wasted running from pillar to post trying to find an answer. All it needs is a team to come together and provide them the management and cure.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

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