While many clinicians view headaches as primarily a psychological manifestation, it is imperative that a complete medical/dental workup be performed. One of the prime causes of muscle tension headaches in the temporal area may be attributed to bruxism and dental malocclusion.
To understand the relation between muscle tension headaches and the mouth, place the tips of the fingers of the right hand on the right temple and the left fingers on the left temple, as though ready to massage the sides of the head. Clench the teeth together, and feel the muscles bulge. When the mouth is closed, do all the teeth fit together comfortably? When the mouth is opened, does the jaw shift to the right or to the left? Do the muscles on the right and left temple contract equally on both sides? If the teeth don't close comfortably and are sensitive to cold or to pressure, if the mouth can't be opened wide without the jaw deviating, if there are popping or grating sounds around the ears when the jaw is opened or closed, or if the muscles of mastication are hyperactive and tender to percussion, then the differential diagnosis of temporomandibular disorder (TMD) must be considered.
The term TMD is replacing the more popular TMJ, which is an abbreviated acronym for Temporo Mandibular Joint Pain Dysfunction Syndrome. This disorder may be thought of as an orthopedic condition, which is manifested by the skeletal malalignment of the mandible to the cranium and the neuromuscular imbalance of the muscles of mastication and associated musculature of the head and neck. When the lower jaw is jolted out of its habitual closure pattern, the teeth do not meet properly and abnormal stress is placed on just a few teeth. The neuromuscular apparatus protects these teeth by preventing complete closure, which results in fatigue of the muscles of mastication. The consequence of this unphysiologic positioning is jaw dysfunction, muscle spasm and pain. The cycle is perpetuated till the opposing teeth are adjusted to meet comfortably and the habitual cycle of pain is extinguished.
Effectively managing TMD requires a two-pronged approach of physically eliminating the noxious dental stimulus and mentally relaxing the muscles of mastication and muscles of facial expression. The use of medication and massage of sore muscles may expedite the healing process. Treatment of the physical etiology may be as simple as polishing fillings that have expanded with the course of time. Other treatment options may range from wearing a specially designed 'bite guard' appliance during sleep (or when stress is experienced during the day), to comprehensive orthodontic treatment and full mouth reconstruction with dental implants, crowns and bridges. But it may be impossible to determine the proper bite relation as long as the supporting muscles are in the clenched or braced posture. Resolution of the disorder requires a coordinated effort. The patient needs to learn how to relax the muscle of mastication and the dentist needs to adjust the bite for optimal comfort. Learning how to relax the muscles and cease diurnal and nocturnal clenching and tooth grinding is no easy task. Approaches range from wearing orthodontic dental appliances or using thin splints, to taking tricyclic antidepressants, to undergoing biofeedback training, to psychiatric counseling, to relaxation/hypnosis training.
The 5-minute relaxation exercise (described earlier) has proven to be a potent means of helping the patient relax so that the teeth can be equilibrated. After the teeth have been adjusted, the exercise is beneficial in helping the jaw relax into the new position. If the muscles are still tense, it's all right to touch the area and massage the tension out. The relaxation exercise, followed by the head, face and jaw massage, should be done several times throughout the day during the acute phase and as needed when there is the sense that a headache is about to erupt.
The cause of bruxism is obscure and disputed. One suggested cause is anatomic interferences of opposing teeth during function or at rest. Children who have nervous disorders exhibit signs of bruxing more frequently (Peterson & Schneider, 1991).
Though bruxism during childhood has few long-term sequelae, the teeth may be permanently damaged. An extended period of forceful bruxism can result in tooth surface abrasion, fracture, or pulpal exposure or necrosis. Destructive affects to the periodontium and tooth structure may be sufficient to cause pain and soreness during mastication. If habit suppression is deemed appropriate and/or necessary, one of the most useful modalities in the management of oral habits that no longer serve a useful purpose is clinical hypnosis.
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