TMJ Friends

How to Get Help When You Are in Pain

If you accept the standard of care that medical providers deem appropriate for you, you are not necessarily going to get the standard of care that you deserve. You HAVE to be more vocal. Medical care now is a partnership between medical professional and patient. Gone are the days when treatment was dictated to the patient and the patient had no other options. Hospital personnel and many medical professionals are overworked, underpaid, understaffed, and in many cases, inexperienced. That is why YOU as the patient, owe it to yourself to be as informed as possible BEFORE you have any procedures done or go in for any type of medical treatment. It is our responsibility as patients to take advantage of the vast resources that we have available at our fingertips.
For most patients, pain management is something that is not always adequately addressed.

• Patients are afraid to admit that they need help
• Patients are afraid to ask for medication
• Doctors are afraid to prescribe because of restrictions placed on them by the government
• Doctor/Patient relationships are short lived because of referrals, so doctors do not know and/or trust the patient enough to prescribe pain medication
• Lack of knowledge by the patient about what is available.

Who Can Treat Pain?

There are pain management specialists who are board certified in pain management. Who you choose to manage your pain will depend on your specific needs. For example, a chronic migraine patient might choose a neurologist to treat his or her pain because the neurologist has more experience dealing with headache patients. Once you choose a pain management specialist, it is usually expected of you to only see that physician for your pain needs. Sometimes the specialist will have you sign a contract, which states that you will only take pain medication from him or her and will consent to random urine testing, pill counts, or other measures that protect both you and the doctor. Some physicians will write you a prescription for emergency room visits that dictate what you should be given in the event of an emergency, what emergency room you should go to, and what medications you are on. This precaution makes emergency room visits much easier.

How is Pain Treated?

Pain management can be trial and error. Medications can be tried for a variety of different symptoms. Most patients find that a combination of different drugs is the most effective therapy. Some of the different types of medications used for pain management are:

• Anti-inflammatories - These medications help reduce swelling and pain. Examples include Relafen, Mobic, Celebrex, Ibuprofen, and Naproxen.
• Muscle Relaxants - These medications help to reduce muscle spasms and tightness. Examples include Soma, Zanaflex, Flexeril, Baclofen, and Skelaxin.
• Nerve Pain Medications - These help to reduce pain due to nerve damage and can also be used to lower pain as a whole. Examples include Neurontin, Topamax, Keppra, and Lyrica.
• Anti-Anxiety Medications - These help to reduce anxiety due to pain. Examples include Valium, Klonipin, Ativan, and Xanax.
• Anti-Depressants - Are used to help with depression due to pain as well as reduce pain in general. Examples include Lexapro, Wellbutrin, Paxil, Nortriptalyine, Elavil, and Prozac.

Opiates

Opiates are used to reduce moderate to severe pain. They are agents that bind to opioid receptors, found in the central nervous system. They are most commonly used for moderate to severe pain.
Short acting opiates, such as Vicodin, Lortab, and Percocet are used for acute or break through pain and are usually prescribed for short periods of time. However, if a patient is taking an appropriate amount, the doctor may choose to keep him or her on the medication for longer periods.
If a patient has been in pain for longer than 6 months, is anticipated to have chronic pain for a long a period of time, or their current short acting medication is inadequate, they can be prescribed long acting opiates. Long acting opiates are slowly released into the system over a period of hours or days depending on the particular medication. Some examples are Oxycontin, Duragesic (Fentanyl) patches, MS Contin, and Methadone. These medications can not be stopped abruptly. They need to be slowly tapered off to avoid discomfort (withdrawal) and side effects. Dosing instructions are for your protection and need to followed very carefully to avoid any potential problems.
In the recent years, there has been a lot said in the media regarding some of the medications used to treat chronic pain since they can be habit forming. There has been and still are many misconceptions concerning addiction, dependence and tolerance with these medications, as well as a doctor’s hesitance or willingness to prescribe them. If a chronic pain patient follows their doctors orders, keeps their medications out of the reach of others (this may involve keeping them under lock and key), signs a pain contract, and is compliant with other precautionary measures, there usually is no danger in taking opiates for the treatment of non-cancer chronic pain.
However, as with any medical treatment, it is best to be knowledgeable about terminology and aware of possible issues that could present. There is an enormous difference between addiction and dependence. They are NOT the same thing.
The dictionary describes addiction as the “compulsive physiological and psychological need for a habit-forming substance.” Dependence and tolerance are also present. And dependence is described as a “physical dependence,” where the body will develop withdrawal symptoms upon stopping the substance. Tolerance is defined as “diminution in the response to a drug after prolonged use.” Many chronic pain patients experience a time when their medication does not work as effectively and they must increase the dosage of the medication or switch all together to continue receiving pain relief. Many chronic pain patients are afraid of addiction, when that seldomly occurs. Less than 1% of chronic pain patients end up addicted to pain medication. Prior drug abuse tends to increase ones chances to becoming addicted to pain medication.

It is important for chronic patients to see physicians who are experienced in treating with opioids. Some doctors are not educated about the differences between addiction, dependence, tolerance and pseudo-addiction. Pseudo-addiction is when a patient displays all the warning signs and symptoms of addiction, however, is actually just under treated and needs their pain managed better.

It is also very important to educate family and friends about the differences explained above. This way they will understand your treatment and not become suspicious or difficult because of your pain management. Taking your family with you to the doctor is encouraged so that they can ask questions and listen to your treatment plan.

Other Types of Treatment

Many patients find that with a chronic pain condition, a multi-disciplinary team approach works best, meaning that one would see different physicians and have different treatment for many of their symptoms. Some of the other types of treatment include:

• Physical Therapy
• Trigger Point Injections
• Massage Therapy
• Acupuncture
• Chiropractic
• Counseling alone or with family
• Support Groups
• Other injections such as facet blocks, nerve blocks, etc
• Biofeedback, relaxation therapies, stress management
• Lifestyle changes

Chronic pain can be caused by a myriad of different problems, such as arthritis, back pain, migraines, abdominal pain, bowel disorders, pelvic pain, fibromyalgia, reflex sympathetic dystrophy, lupus (and other systemic autoimmune/connective tissue conditions), multiple sclerosis, along with TMJ disorder, facial pain, myofascial pain, and other related conditions.
Medications also work for different conditions, and can be used for different problems or symptoms than what is listed above.

If you have questions about your pain, treatment, medication, side effects, dosing, etc please contact your pharmacist or physician.

Chronic pain affects more than 75 million people in the United States and costs over 100 billion dollars per year. It is an important issue that often overlooked and under-addressed by both patient and doctor. Hopefully with advent of the internet and more knowledgeable patients & physicians, less people will suffer needlessly in pain.

If you have any questions about pain management for TMJ disorder or other painful conditions (such as back pain, fibromyalgia, chronic fatigue syndrome, migraines, atypical facial pain, myofascial pain, reflex sympathetic dystrophy - RSD, chronic regional pain syndrome - CRPS, etc) the questions page on the website lets you know how to submit questions that will be featured on the TMJ Friends blog.  For support from other patients, visit our message board.

Meanwhile, take care of yourself and don’t forget to get a good night’s rest, try to eat nutritious foods, and exercise if you can.

TMJ Disorder: Where Do I Begin? Part I
What Type of Doctors Treat TMJ Disorder?
This article is the first in a two part series for people who have just been diagnosed with TMJ disorder or those who still have questions about the process. Since TMJ disorder effects so many bodily systems and can produce so many different symptoms, a variety of doctors treat the disorder. Through much trial and error, we have found that a team approach is the most beneficial and produces the best results. This article will go over the type of doctors you may encounter in the course of your treatment.
These doctors will be listed chronologically, however, since each person is different, your specific treatment plan could be different as well. Some of us start with a neurologist because of the headaches brought on by TMJ disorder, others start with a surgeon because their problems were brought on by trauma. This will just attempt to summarize each doctor’s role in the treatment of this disorder.

The first stop in many patient’s treatment is their general or family dentist. The dentist will check for a number of signs that indicate TMJ disorder is present. These include tooth wear from grinding or clenching. He may also begin by listening to the jaw with a stethoscope to check for popping, grinding, or any other sounds that may not be consistent with normal jaw function. He will palpate and apply gentle pressure to your face, neck, shoulders and/or back. Depending on your dentist’s training or specialty, other tests might be done, which will explain later. If you do have any of the symptoms as explained above, your dentist may do one of several things. He may fabricate a splint which prevents further tooth wear and helps pain. Keep in mind that the splint is a trial and error process. It will require many visits to adjust the splint to get maximum benefit. You might also need to try several appliances before finding the right one for you. The dentist might also prescribe medications such as anti-inflammatories and muscle relaxants, or he may refer you to our next professional, the “TMJ specialist.”

The TMJ specialist is a dentist who has usually had extra training to help him become more familiar with TMJ disorder. It is always a good idea to ask the dentist what training he or she has had. Please refer to our article entitled “How to Choose a Doctor” for more information. The TMJ specialist will most likely do a more extensive examination than your general dentist. He might take different types of x-rays such as a panorex or tomogram, or order an MRI. You may question why to see a general dentist if you could just see a TMJ disorder specialist.

Most cases are manageable at the general or family dentist level, and do not need further intervention from a more specialized doctor. Keep in mind that these cases can be managed without invasive or irreversible treatment such as grinding your teeth down or changing your bite. If this is proposed, you may feel the need to secure a second or third opinion. The TMJ specialist will be your primary diagnostician based on results from tests, physical examination, your symptoms, how your teeth fit together, etc. Depending on what your diagnosis is, this doctor may do a multitude of things, like splint therapy, trigger point injections, iontophoresis, ultrasound,transcutaneous electric nerve stimulation. They may refer you to other doctors such as a neurologist, ear nose and throat doctor, pain specialist, or oral surgeon. This doctor will come up with a treatment plan for you which can include any of the above. Usually they refer to this treatment plan by “Phase One” and “Phase Two.” Phase one is generally reducing pain, stopping any inflammatory or degenerative processes. This part of the plan is usually conservative. When your pain has subsided, and a correct diagnosis has been established, you move on to Phase Two, which can include braces, equilibration and total reconstruction including crown work and bridges. These treatments are non-reversible and invasive. Please keep in mind that this varies from doctor to doctor. At this point of treatment, many patients see a psychologist to help deal with the pain and associated effects of TMJ disorder on their life and their family. This is a very important aspect of treatment.

Please keep in mind that there is no board certification for “TMJ Specialists.” Any doctor can call themselves a specialist, whether they have had 5 hours of education on TMJ disorder or 5000. This makes it extremely important to do research on the particular physician you choose.

If the patient has headaches, burning pain, migraines or any neurological symptoms, they can be referred to a neurologist.

The Neurologist is a doctor who specializes in nerves and diseases of the brain and spinal column. Some patients with TMJ disorder see a neurologist for a headaches or facial nerve pain. A neurologist’s examination includes checking reflexes, strength, eye movement and nerve reaction. He might listen to your jaw joints with a stethoscope.
If you haven’t had an MRI by this point, the neurologist might order one.

The next installment of this three part article will cover Ear Nose and Throat doctors, pain management specialists, and oral surgeons.