Why Are So Many People Misdiagnosed With TMJ Disorders? With Professor Renton (Ep 173)

Transcripts are auto-generated and may contain errors

Tara Renton: [00:00:00] Dentistry again is special in that we do really quite high tech difficult surgery in a difficult area, in the mouth on the most difficult nerve in the body. The trigeminal nerve is the one, the one nerve that protects all your eyes, your nose, your mouth, all the things that underpin our existence, our identity, and if you have pain in this region, it's pretty horrible.

It takes over your life.

Dr. Linda Bluestein: Welcome back every bendy body to the Bendy Bodies podcast. I'm your host, Dr. Linda Bluestein, the Hypermobility md. A Mayo Clinic trained expert in connective tissue disorders like EDS, helping you navigate joint hypermobility and live your best life. Today we'll be talking with Professor Tara Renton. I am so excited for this conversation because we're going to be talking about temporal mandibular dysfunction [00:01:00] or what a lot of people call TMJ.

So when you say TMJ, we're actually referring to the temporal mandibular joint, so we all should have that. But dysfunction of that joint is a whole nother story. Joint pain. The jaw is so extremely common and is something that I've struggled with for such a long time. We're gonna talk about the muscular aspects of this pain, how the joint can be affected, whether or not imaging is helpful, whether or not injections like Botox are recommended and so much more.

Professor Tara Renton is a specialist in oral surgery with an extraordinary background in dentistry, oral and maxillofacial surgery and neuroscience. She leads internationally recognized multidisciplinary research in third molar surgery, otherwise known as wisdom teeth surgery, patient safety, trigeminal nerve injury, and oral facial pain.

With over 250 peer-reviewed publications to her name, professor Renton also founded several patient-focused resources, including trigeminal nerve.org.uk, [00:02:00] oral facial pain.org.uk, and the new website app face your pain.org designed to improve oral facial pain diagnostics. I'm so excited for this conversation because of the fact that I suffer from jaw pain and so many of my patients do.

As always, this information is for educational purposes only, and it's not a substitute for personalized medical advice. Stick around until the very end. So don't miss any of our special hypermobility hacks. Here we go.

Okay, we're back with Professor Renton, and I'm just so excited to chat with you today. As I mentioned in the introduction, I have had problems with my jaw for so many years, so this is a topic that is really, really personal to me. It is a very common problem, and particularly in people with bendy bodies.

So can you share how you became involved in developing the UK guidelines for TMD management and why this is so important for people with connective tissue disorders like EDS and HSD? 

Tara Renton: I'd be happy to, I have [00:03:00] to go credit to the lead author Emma Becroft, who's a phenomenal young oral surgery trainee. Um, she actually led the review and Justin Durham, who's another professor of oral surgery up in Newcastle of a great friend, a colleague of mine also was a driver behind those guidelines.

Um, I, uh, was involved, uh, partly because I published an awful lot around Oracal pain. Um, I was involved in the international classification of Oracal Pain draft one, and I'm currently involved in the draft two, which is basically where we aligned all the different oracal pain conditions with international headache, uh, IHS and IHCD.

So it was the first time we actually aligned all the headache and face pains together. Um, and as part of that, um, that's how I got involved in the, in the TMD guidelines at the Royal College. 

Dr. Linda Bluestein: And what were the biggest goals or unmet needs that these guidelines were aimed to address? 

Tara Renton: Well, um, there were some previous guidelines, um, [00:04:00] and such disparate group of disorders.

It's often poorly understood as a huge amount of work that's been done in the, in the US around t MDs and looking at different classifications, looking at evidence-based for diagnosis and treatment. But somehow this, this just wasn't translating into clinical care. And what Emma and Justin really succeeded in doing with the guidelines is actually, um, coming up with, uh, a interactive, um, get it right first time, which is an English thing around trying to optimize care at the first visit rather than patients coming back and back and getting the wrong diagnosis and having too much treatment.

Um, and they've basically optimized it with a lot of online. Um, support. So you have videos around dietary habits. You have videos around physio, about self home exercises. Um, the, it's the first time there's been guidelines. I chaired the third molar guidelines many moons [00:05:00] ago, uh, for the, for the Royal College.

It's the first time they've actually had all this online, uh, presence where dentists can actually, and doctors and any clinicians involved in managing a patient with these problems can actually go online and, and the patient can download a huge amount of resource. And what I love about it was holistic care.

So one of the first things which I dunno if you've read any of my research, I'm very into patient-centered treatment management and diagnosis. The ethos behind this was to get dentists to think about anxiety, depression as one of the presenting features in chronic pain. Um, and they've introduced the PH.

PHQ four, which is a very basic four question questionnaire, which is around, gives you an indicator of an degree of anxiety and degree of depression. It's not a, a, a high level indicator, but it gives you an idea of those, those problems. So that's one of the things that it talks about. And then it also looks at jaw functions.

So there's a very short questionnaire around jaw function, [00:06:00] and then there's a questionnaire about the, the pain in your jaw. So there's three very simple questionnaires that you hand to your patient. Um, it's holistic feedback. You can get that score back and it gives you an indicator of how badly affected the patient is, how daily function is impacted, and generally giving you a better idea of how to better manage that patient.

Dr. Linda Bluestein: I really love that for a couple reasons in particular, one, get it right the first time. I feel like with so many people, if they've had a problem for a long time, people kind of stop really trying to look for the root cause. So I feel like that's absolutely right. The first time is the best time to really get the right diagnosis, figure out what's going on.

And um, the other part of that that's so valuable is. Like you're saying, how it affects your day-to-day function, because I hate pain scores. I hate the visual analog pain scale because, you know, some, somebody could report their pain as, as a 10 or a five or a nine or whatever number they're gonna give it.

But really what we wanna know is how is that impacting them on a day-to-day basis? [00:07:00] Because that's really what's important because everyone feels pain so differently. So the functioning piece of that is, is so fabulous. And I've actually gone on your website and I've gone through the tool myself, so I, I I love it.

I think it's really great. Interesting. 

Tara Renton: Well, thank you. And, and actually having a wonderful example of how, how useless the visual, visual analog scales are for pain. And I remember this lovely patient. He was a middle-aged professional man, and he had been treatment seeking a lot for this pain that he had.

And when I asked him, which is part of the rating, the Socrates pain rating, his level level severity of pain, he said, oh. About a two outta 10. And I was thinking that doesn't match that level of pain he's reporting on a daily basis did not match his treatment seeking behavior. So I thought, I said to him, have you ever fractured, fractured a bone?

'cause I dunno if most people in the audience probably have fractured a bone. I fractured my wrist, I skating with my [00:08:00] daughter a few years back, and you get that guts horrible deep. It's almost part, it's a bit like trigeminal pain. It's very emotional and it's very, there's a sort of autonomic drive you, you know, that you've done something really bad.

And um, and I said to him, he said, yes, actually, I've broken my leg playing football and I broke my arm skiing. And I said, so what pain did you have with those? And he said, probably about a one. Oh my gosh. So, so that, that's explained, you know, so different people feel pain differently and it's, um, their visual analog scale is just not really fit for purpose when it comes to diagnosis and managing patients.

It, it might help you in that patient rate the success of treatment you, or interventions that you're doing, but apart from that, it really doesn't have a whole lot of use. 

Dr. Linda Bluestein: Yeah, totally agree. For, for listeners who might be relatively new to this topic, could you define temporal mandibular disorders for us and, uh, why they're so common?

Tara Renton: Well, uh, temporal did. [00:09:00] Disorders, a bit of a mouthful. Basically your jaw joints. Uh, so first off, the jaw joint is what is the most complicated joint in the body. So first of all, it's got, its, its partner on the other side, joined by one piece of bone, so there's no other joint in the body that has another joint on the other side that has to coordinate with.

The second thing is the joint actually is a ball and socket joint, but also it slides outta the joint. So there's a rotational movement and there's a translational movement. So the jaw head actually leaves the socket, technically subluxing or dislocating, but not 'cause the joint capsule is in one piece, one piece.

So, so the joint is really, really complicated. That in part explains. And also you've got the teeth. So again, um, your hip joints and knee joints have just got your feet. Your feet are pretty pliable. We all wear high heels and platforms and bouncy shoes and flat shoes. Your, your joints can put up with that.

With your teeth. It's very accepting and very, the [00:10:00] proprioception is absolute about understanding that your teeth are functioning properly and they're meeting together. So, so there's, we're talking micro micrometers of, of measurements to, to make you comfortable about the way your teeth bite together. So those poor joints have a really big job.

And that may in part explain why we do see some tempera mandibular disorders. They're basically divided into androgynous, which is joint based or myo, which is muscle based. Those are the two main groups. And you may have a third group where they have an element of both. So, so that, so really those, the, the, the, those are the, the, the jaw problems very basically described.

And the androgynous are basically, uh, described as clicking. So I told you about the rotational movement and the translational movement. There's a meniscus or a cartilage, which is tethered to the joint space on front and back of the joint. And that has to travel in synchrony with the [00:11:00] condyle head, the jaw head.

And if it doesn't, you get clicking. And if that, if that meniscus gets trapped in front of the jaw as it moves forward, as you open your mouth, then you get locked opening. And if it gets stuck behind when you, when you open your jaw, you can get clothes locking. So people go to yawn and they can't cry, or they go to yawn, they put their teeth, they, and they can't open their mouth.

So that's what we call disc dis uh, disc dislocation with or without reduction. So, so those are the, and the, so those are really the main. And we know that you can get arthritis and rheumatoid arthritis and different in the jaw joint, so those, the jaw joint conditions. Uh, conditions are basically tenderness of the, um, of the temporal muscle, which you have a fan muscle on the side of your head here, temp, uh, tenderness of your master muscles.

And that's basically how we [00:12:00] diagnose and tenderness of the joint itself, which may be part andogenous, part aous part directly due to the joint. So, so we, there's been some studies around. Uh, OIDs inflammatory markers in the joint space. Um, there is, um, a definite link with, um, uh, this pain with estrogen depletion, with stress, with lack of sleep.

Um, the big question at the moment is about the function, and a lot of people, um, relate, uh, clenching habit during the day, or nocturnal bruxism or daytime bism, which are grinding your teeth. A lot of people have over the years related that to joint pain. And the recent evidence is really indicating that actually bruxism does not, and clenching does not drive jaw muscle pain or jaw joint pain really.

So that's a good myth to sort of, um, and, and also the evidence for, for splints for jaw pain are quite equivocal. Mm. [00:13:00] So, you know, there's, there is, there isn't an indicator unless it's for, for personal comfort or, or, or. Personal effectivity, everyone responds to different treatments differently. There is no indication to spend, you know, $4,000 on a, on a, a special splint than there is basically just to have a simple blowdown splint.

And what those splints are doing is they may be symptomatically helping the patient. There may be a placebo effect. What they are doing is they're protecting your teeth from the grinding and the bruxism. 'cause obviously the dent, the, the grinding and the bruxis does damage your teeth. Particularly if you're old like me with lots of fillings.

Um, then your teeth will break and fracture. So that's what the main indication for the splint are for those conditions. There is, um. There's some very interesting, uh, um, evidence coming out at around nocturnal bruxism, which, um, coincides with, have you heard of paroxysmal limb movement? So, you know, when you wake up in the middle of the [00:14:00] night and you've like tripped over a pavement, that's your, um, some people call it restless leg syndrome during the day.

Um, if you have this limb movement at night, that's due to arousal phases in your sleep, and that's when nocturnal bruxism has occurs. So there's more interest now of reclassifying nocturnal bruxism as a part of a sleep disorder. Which is really, so a neuromuscular sleep disorder. So that's, that's where we are with the different joint conditions.

And I also have to say what's also is increasing evidence is the comorbidity of migraine. And, uh, I'm, I'm, I'm a bit out there that the evidence isn't there yet, but I have this empiric feeling that, um, around 60% of my patients with erogenous TMD, which is by far the most common, they have comorbid migraine.

And I sort of feel that probably the migraine is, is, you know, people, many, many of your audience will have migraines. It's very [00:15:00] common, 

Dr. Linda Bluestein: very, uh, 

Tara Renton: when you have a migraine, it affects the whole side of your face, not just up here. It affects here and here. And we know with migraine you get sensitivity to touching your skin, brushing your hair cold sensitivity.

So why would that not. Why would that not affect the muscle sensitivity and the joint sensitivity if you've got the MI background in migraine? So, and obviously there's a huge hereditary factor to migraine as well. So there's a, there's a couple of really nice themes coming through and we have, you know, we have, um, a screening for migraine, um, in, in we've, we recommend screening for migraine in the guidelines, which is also part of the holistic assessment.

Dr. Linda Bluestein: And migraine is so, so common in people who have HSD and EDS. It's so, so common, 

Tara Renton: incredibly common. It's sort of part of that picture really. Um, and that's something as dentists, you know, we're not trained in psychology, we're not trained in headache, urology, or headaches. We haven't got a clue. And it's only the reason I.[00:16:00] 

Been introduced this because I did a PhD in nerve injuries related to wisdom teeth. I'm a max back surgeon by training and that's how I ended up finding out about nerve pain, which no one knew existed in those days. It was a relatively new, um, invention, neuropathic pain. Um, and that's how I ended up running pain clinics for people.

And then I ended up working with. Clinical psychologists, psychiatrists, headache, neurologists, uh, ENT, uh, neurosurgeons. And we've, it, it's a very fertile ground, but I've learned so much from the headache neurologist and how important it is to ask about screen out migraine. We use a HIT six, a very simple six question question, six question questionnaire, which gives you an indicator of, of the impact of migraine and it gives you an idea if the patient's affected by migraine.

And then, um, and then of course working in the clinic with the headache neurologists. And we also see some very other interesting primary headaches as well, like the cluster, cluster headaches, which are rarer but very impactful and also cause [00:17:00] pain in 

Dr. Linda Bluestein: the face. So we know that people with EDS and HSD are definitely, uh, increased risk of having migraine, but why do you think, in addition to that, why are they so vulnerable to having TMD?

Tara Renton: Well, as I've said, I think a big proportion of myo TMD, which is. The most common is probably in part due to my, the migraine background. That's my philosophy. So I think that that is, and it's, the evidence is not there yet, but I'm, I'm, we've, we've, we've got a paper coming out. There's a couple of papers around treating mi um, TMD, myo TMD patients as a migraine patient, and their symptoms go away, really.

And if you think, yeah, and if you think about the prevalence and the, uh, of migraine, so onset of migraine happens, uh, beginning of menstruation in many women. Um, and that's, that's TMD often starts then as well. TMD happens around, um, stressful periods of life, so rarely [00:18:00] as early on as changing schools, but that's becoming more common in younger and younger people.

But exam time, so 16 to eight in exam times, going to university, that's the sort of peak. Of MDs and then it comes back again in later life around divorce redundancies. So stress is a big, big driver and stress drives migraine. So, um, it's, you know, it's not a slam dunk. Uh, it's more of a sort of, uh, association rather than a direct cause.

But I'm, I'm beginning to believe that actually that that migraine background will make you more at risk. The, you know, the, the CGRP low threshold release, which is what causes a migraine, is somehow embedded in a lot of the other conditions that we see. What 

Dr. Linda Bluestein: about the connective tissue laxity? Does that contribute to the instability of the jaw?

Yeah, absolutely. 

Tara Renton: So in the jaw, in the androgynous group, I talked about clicks. Mm-hmm. And I talked about locking close locking, open locking [00:19:00] without resolution. And yes, for sure, because the jaw joint has a capsule, it has the meniscus with the ligaments front and back. And those ligaments, if they're, if they're stretchy.

Like, you know, in pregnant PE people, people on steroids and people with HSD and Ed, then, then they're gonna be more lax. That minister's gonna have more ability to go too fast, too forward too quickly, or stay back behind when it shouldn't, because the ligament at the front is too stretchy and that will give them locking, give them clicking, clicking, give them, you know, jaw dysfunction 

Dr. Linda Bluestein: so to speak.

What about the comorbidities that we commonly see with EDS and HSD? So for example, um, pots, postural, orthostatic tachycardia syndrome, mast cell activation disorders, small fibroid neuropathy, central sensitization, et cetera. How do you observe those influencing TMD severity or the treatment? Absolutely 

Tara Renton: dysautonomia.

I mean, it's, we, we, we do, we see that. We don't look for [00:20:00] it as much as we should do. I, I interestingly diagnosed a patient with that just this week actually. But, um, it's something we don't look for enough. Um, we certainly screen all our patients for comorbid back pain, neck pain, headache, TMD, and it's been very well published for those comorbidities coexist.

Did those papers 20 years ago look at HSD, look at Ala Danlos. No, they didn't. And it would've been very interesting to look at. The proportion of patients would've been a high number of patients, I suspect. 

Dr. Linda Bluestein: And, and what about imaging findings? How helpful is that, especially in people with connective tissue disorders?

Tara Renton: Not, not helpful at all. I mean, not at all. TMD, the di, not really. Noel. If you've got someone who's repeatedly dislocating and cannot. Cannot reduce the dislocation, then you want to actually have a look. But, and if you've got someone who perhaps is presenting with severe arties, you may want to have a, uh, uh, an MRI scan or a CT scan of the joints.

But generally, TMD [00:21:00] is a, is a clinical diagnosis, like post-traumatic neuropathy is a clinical diagnosis. Um, imaging is not that helpful for. Pain conditions like, you know, there was a fantastic study in America around 20 years ago where they looked at knee pain. They did sham arthroscopy in half the patients.

There was no difference between not doing the arthroscopy and doing the arthroscopy. I mean, uh, but very interestingly, the imaging shows that you could, you could not predict based on the radiographs of the knee, whether there was pain or not. It just doesn't compute. There may be, there may be an opportunity with a new development, which is MRN, which is Mr.

Neurography, which I'm involved in, in the head and neck region. We're just developing it at Kings. Um, and there's, um, it's well established in the states where you can see nerve tissue and you could see some, um, arteries, uh, using specific MRN and that may be more useful and it may actually enhance some of the soft tissue, uh, imaging too.

But that probably the [00:22:00] nerves is probably one of the things we probably most want to look at. But that's probably not relevant for TMD. 

Dr. Linda Bluestein: I have so many patients that have been to chiropractors and oftentimes they've had imaging of their backs, and some of them are very young, and the chiropractor has said, you know, oh, you've had the worst, you have the worst back I've ever seen.

The worst spine I've ever seen. And so one of the downsides I think, for imaging is, like you said, it depends on if it's gonna change what your next step is and that kind of thing. Of course, that's, that's important, but sometimes I feel like there are things that are said that influence. Our pain and our ability to improve because we have, we feel like there's just no way I can get any better.

'cause I have this terrible damage in my body. And there was a study that looked at, uh, the radiologist put in their report, um, on half the patients they put at the end age related changes, or these changes are consistent with age or something like that. And in the other half they didn't do that, and they found that those patients did better than the ones who did not have that in the report.

So, so what would you [00:23:00] say to people who say, yeah, but I had imaging done and they saw that I had damage, therefore I'm always going to have pain? 

Tara Renton: Well, depends. I mean, I'm not a, I'm not a spinal expert as it pertains to the jaw. Sorry. 

Dr. Linda Bluestein: Yeah. 

Tara Renton: Yes. Oh, to the jaw. Yeah. I, it frustrates me that any test, like a blood test, could be the worst possible result.

You know, the patient's not the expert, the patient doesn't know what those results actually imply. So I think it's a, I think without explanation of why that radiograph or that imaging. Something particularly wrong. You know, if they've got a, um, a disc herniation or something like that that's not picked up before then that's significant.

But actually you pain diagnosis, as I've mentioned, is a, is a, is a clinical diagnosis. And I think it frustrates me that what is often, as you've alluded to with the study, you mentioned often the reference to how bad the x-ray is, is almost reinforcing the patient's need for [00:24:00] treatment that that clinician wants to give.

And I find that, you know, without casting aspersions, I find that very frustrating. And it, it really, you know, if you take radiographs of, of most people's jaws, you might find a bit of erosion. You might find age related changes. Um, but you, but you, you're rarely, you know, you're not gonna really, unless it's a fracture or there's some neoplasia or some pathology, you are not gonna find a lot wrong with the jaw joint.

Dr. Linda Bluestein: And it's so frustrating 'cause it goes both ways. 'cause there's also people who have things like compression syndromes or cervical instability and their, their imaging is red as normal. And because the radiologist isn't necessarily looking for these really, really fine points or they're not assessing it during movement.

Um, so I, I love what you said about doing imaging, you know, while opening and closing the, the mouth because, you know, there's, there's a lot more than just what we might see on those static, um, images as well. 

Tara Renton: I 

Dr. Linda Bluestein: think the [00:25:00] hope there may be AI in the long term. Mm-hmm. And based on the UK guidelines, what does first treatment first FirstLine treatment look like for most TMD patients?

Tara Renton: So essentially it's reassurance information. There's a lot of, um, uh, information for the patient on the, on the website that they can download. There's videos as well. Um, so be it, very empirical, um, non reversible strategies. So, uh, reassurance. Pain management advice around diet and daily activity, maybe reducing soft diet, possibly uh, stifling yawns.

Um, uh, obviously you've got patients who love singing or play wind instruments. You may have to sort of try and see if they can modify their behavior in that respect. As far as stressing the jaw, opening wide, we know that you know every time you go to the dentist, you are often, if you're having, uh, prolonged procedures like wisdom teeth, extractions, or crown and bridge work, you are, you are there, you're sat there with your mouth [00:26:00] open for a long time.

Your dentist should be giving you a prop so you can relax with your mouth open and that 20% of patients after prolonged dental treatment will get jaw pain. Get muscle pain or joint pain and that can be mitigated by just giving you a propped rest on whilst you are having the treatment. So you are relaxed with your mouth open.

So there's a lot of preventative strategies and things that you can say to your patient next time you go to the dentist. If your history is good, you'll find out that most of the time they're getting the jaw pain is after general anesthetics or visiting the dentist or after they've done choir practice.

So there's things that you can pick out and and modify their behavior and try and help them in that way. And then the next level is possibly a splint. Um, uh, an occlusal splint, which is empirical, as I've mentioned. There's very little evidence to support that, that actually helps You would've screened out if they've got high levels of anxiety, depression, which is very early on in the screening.

You need to refer 'em to someone. Uh, their gen. We have general me medical practitioners in the uk you have your physicians in the us you would refer 'em there to, uh, to, for [00:27:00] perhaps psychological intervention. Um, and then the jaw function. So that's mitigating the movement and diet and. Splints might help that patient if they come back after, um, six weeks with, with minimal improvement.

And then if there's, um, obviously you want to look at red flags early on. So if they've got increasing trismus, so if their jaw is, their opening is reducing more and more, that's a significant issue. All those red flags we think about, persistent lymph lymphadenopathy, night sweats, weight loss, uh, previous reported cancer, those are all things that we think about.

But that's a very small proportion. But if those red flags come up, that's an urgent referral. That's a, we have a neoplasia or suspicious lip. Referral network within two weeks in the NHS. So these things are all flagged out very early on, but for once flagging out the anxiety, depression, flagging out the red flags, then you treat the patient basically with, um, symptomatically with reversible strategies.[00:28:00] 

And then basically you work down the algorithm as three levels. And if those patients don't respond to that, then they go on to secondary referral where they might get a splint made or they might get, um, more treatment. And probably most of those patients probably have ongoing migraines, so probably better management of their migraine, which their GP can, can, can address.

Dr. Linda Bluestein: I wanna point out too that, um, with anxiety and depression, those so commonly occur with any kind of chronic pain, right? And if we don't address the anxiety and the depression, we're not really gonna make headway in terms of the pain. And I know, you know, some people might think, oh my gosh, you're saying that the pain's all on my head.

But, but this is where we feel everything is between our ears, right? That, that is where we process all information. So we, in one sense, it is all in our head, but we're, that doesn't mean that we're making it up. P pain is always real. It's always what the person says it is. Nobody else knows what kind of pain you're feeling.

It's just what you feel is what you feel. [00:29:00] Um, but I think a lot of people maybe misunderstand this link with the anxiety and depression and don't realize that it's just that those things, when they coexist with. Persistent pain. There's just no really good way of getting the pain better unless we also address those as well.

Like with sleep, if somebody has poor sleep, we have to address that in addition to addressing the pain, because otherwise we're just not gonna make headway. Would you agree with that? Uh, 

Tara Renton: I absolutely agree with you on so many counts. I mean, the first thing is. Mood disorders, anxiety, depression, have, have basically followed the same pathways as chronic pain.

So healthy pain's different. You know, we park that healthy pain protects you. You've got an infected tooth, you've got your fingers stuck in the, in the door, you stubbed your toe. Those are healthy pains telling you you've done damage to your body and you need to stop doing it or take it away and you need to rest.

We've gotta fracture. Rest your leg, let it heal and get back on it. Healthy pain is healthy. Pain usually resolve within a few weeks alone, three months. Chronic pain is [00:30:00] different. It's either nerve pain or neuroplastic pain and probably a lot of the, um, neurovascular pain and the ous pain could come under the sort of neuroplastic, fibromyalgia type, uh, un you know, unexplained pathways, whereas the nerve injury pain is better explained.

So those two types of chronic pain, there is a disconnect between where we feel the pain in the somatosensory cortex on the opposite side of the toothache or the finger ache. And what happens is once that's healed. For some reason, and you mentioned Sens sensitization, you mentioned, um, some of the mechanisms that may cause this memory of paint to persist.

We, I refer to, Emma uses the term text messaging. So it feels like your tooth is still text message messaging, your brain saying, help, help, help. But actually all the tissues there are healed and they're completely normal. And it's a disconnect between the midbrain, which is where the trigeminal neurons are, and, and the limbic system anxiety, depression, which we know if you have, you know, [00:31:00] anxiety, depression, then you are more likely to develop chronic pain as, as similar to, um, certain types of personality.

Um, types even know you're less resilient, you're more likely after simple procedure to have chronic pain. That's absolutely the case for anxiety depression. So those shared neural pathways are sort of like. Making each other worse 'cause they're sort of competing. Um, so anxiety, depression has to be looked at in any kind of patient presenting with chronic pain.

Mm-hmm. 'cause as you've mentioned, if you don't deal with that and sleep disorders and other issues, prior life adverse events and other things, you are not gonna manage that patient's chronic pain. 

Dr. Linda Bluestein: Yeah. And I think on the one hand it can be, when I first learned about catastrophization, it was kind of like, oh my gosh.

You know, but it's a little bit empowering because you realize, okay, here's some modifiable factors. Like, I know I've had lifelong anxiety. If I address my, uh, me personally, I'm talking about myself enough. I, I, when I realized by addressing my lifelong anxiety that that would help [00:32:00] with my pain, that was. A lover that I could pull.

And I love the text messaging. That's really great. My tooth is still text messaging. It's good, isn't it? Yeah, it's really good. 'cause I think, you know, now we can all relate to that 

Tara Renton: visual. Yeah, yeah. It's a Thank Emma for that. She's, she does a really lovely lecture actually on chronic pain. She's a bit of a star, but, and she was the one that led the TMD guidelines, so, um, guidelines.

But I love that analogy. And, and yeah, patients definitely get that. Yeah. Yeah. 

Dr. Linda Bluestein: We, we can really relate to that. Okay. We're gonna take a quick break and when we come back, we are going to talk about some of the therapies that people are doing for TMD, like prolotherapy, PRP, and are these things really helpful or not physiotherapy, um, et cetera.

So we'll be back. Very soon.

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We are back with Professor Renton, and I am so, uh, curious to ask you about injections and some of these procedures that get recommended so often to patients. And we're gonna talk about local anesthetics and a whole bunch of other things, but first in this like earlier phase of treatment, I want to talk about [00:34:00] physiotherapy.

When is that helpful? How do you identify a therapist with appropriate training? Um, what are your thoughts on that? 

Tara Renton: Well, certainly physiotherapy does have a role in patients who perhaps don't respond to just simple, uh, step one in the, in the Royal College of Surgeons guidelines, which is basically reassurance, some sort of habitual changes.

So sort of the, if once reassessed at six weeks and they still have some symptoms and they haven't perhaps completely resolved or they've just partially resolved, then you think about perhaps, um, adjunct, uh, treatment. I mentioned splints, even though they have very equivocal evidence base. Um, we talk about acupuncture and physiotherapy.

So those have a moderate, uh, evidence base in managing patients. I think you have to be very careful. Um, uh, acupuncturist, acupuncture. I'm not an expert in the area, but I know it helps an awful lot of my patients with lots of different types of pain conditions that we see. Um, uh, but the physiotherapy is.

Your questions around finding someone who knows what they're [00:35:00] doing is again, there is resources on the Royal College of Surgeon's website, which shows you what sort of physiotherapy might be appropriate. Some patients will get worse with it, 'cause more mobilizing of their joints will actually cause more irritation and pain, whereas other patients seem to respond very well to it.

So again, that's a sort of personal take and different people will respond differently. But that's a sort of second stage treatment for patients. Uh, and again, in the guidelines, they'd be reviewed again at six, two week weeks after those interventions. Um, and, uh, hypnotherapy is not, not measured, um, not mentioned, um, but I've, the step two also talks about the self-referral for anxiety depression that needs to be managed.

You know, morbidly to make sure that, concurrently, to make sure that those are, those issues are addressed as far as more interventional treatments are concerned. So you mentioned injections, so arthrocentesis, which you might wash the joint out, you might inject different steroids. [00:36:00] Sometimes, um, some thickening fluid to help the joint work better.

PRP, there's, there's really limited evidence around doing that. Um, I've seen many patients over the years who symptomatically get some relief from that. But, uh, it's, it's, it's not evidence-based. And then write down the look line where patients are having. Jaw replacement surgery, it really is very, very, very rarely indicated.

And usually for patients who've had old fractures, OID fractures, maybe they have pathology, um, or they have, uh, congenital disorders where the jaw joint hasn't completely formed. But actually surgery is not something that should be indicated for T MDs and other interventional treatments. As we say, we very much err on reversible treatments and those treatments are not reversible.

Did you mention hypnotherapy in there? Yes. Um, hypnotherapy along with, um, well, it's not evidence-based, but a lot of my patients have responded very well to that. But that's [00:37:00] not in the guidelines. It's not sufficient evidence-based to put it in the guidelines, not as much as physiotherapy and acupuncture.

Dr. Linda Bluestein: I, I was hypnotized once, and it was really fascinating because, um, I was in so much pain. I actually was sitting next to this psychologist who did a lot of hypnosis, and he was explaining to me about hypnosis and, and the role that he felt was, um, really valuable in, in chronic pain. And at that time, my pain was so poorly controlled and I sat there and he walked me through the whole thing and I, you know, you're going down the staircase or whatever it was that you're doing.

And when he was getting ready to take me back out of it, I was like, no, no, please don't, because my pain did go away. From the neck down interest felting felt. Yes. Yes it was. And I'm very, I'm probably like one of the best people for this kind of therapy. I think it probably, there's probably a lot of individual variation in terms of the susceptibility to it, but, um, it was very successful for me that one time.

But it really just made me [00:38:00] realize how powerful the nervous system was in processing pain signals. Because if by being hip, he didn't touch my body, you know, he just hypnotized me and I was, I could feel nothing from the neck down, which meant I also could not feel pain from the neck down. Um, so that was really, really a fascinating experience.

That's just an anecdote of course, but it was very, um, interesting. 

Tara Renton: It's really interesting and I have, you know, it has helped relatively few of my patients, but if you think about it, I mean, if we could harness sleep. So sleep, basically, you know, the, the deep phase of sleep you have no, you are still breathing, your gut's still working, your heart's still pumping, but actually your somatic sensory system is shut down.

Um, and it would be very lovely to harness that, and that's probably what hypnotherapy is doing. It's like doing the ultimate downward pain modulation at the midbrain and stopping the, the feedback coming up. Um, and that's probably the mechanism. [00:39:00] And if we could harness that, and it won't, it won't be a drug and it won't be an injection.

It'll be using this better, using those soft skills, giving patients the ability to be able to do that kind of thing. And, and a lot of what we do is actually trying to enhance downward pain modulation, you know, gut health. Um. Treating psychological morbidity, explaining, giving them clear diagnosis and prognosis.

Um, all those things will help patients manage their own pain. And that's probably the best thing we can possibly do for the patient is not sign them up for another drug or another injection or another newfangled treatment that came out, you know, last week and, you know, maybe have FDA approval. But I 

Dr. Linda Bluestein: think, I think a lot of 'em, a lot of them don't, but Yeah.

And, and just to clarify too, that we're talking about the unhelpful part of pain, right? You're saying if you have a, you know, there's lots of pain that is helpful, that is important and necessary so that we know to make a change, right? So there's pain that is telling us [00:40:00] we need to change something and there's pain that's.

There, but healthy pain and 

Tara Renton: unhealthy pain. And unhealthy pain is basically, um, a pathology, a disease of the, of the neuro system. So, so chronic pain is where the neuro system is dis, you know, the texting is still going the to the cortex. Somatosensory causes are saying, the brain's saying, oh, I've still got pain at my foot, still got pain in my foot.

But actually the foot's completely fine. It's the, it's the nerve and the junctions on the way to somatosensory cortex that's allowing this, generating this texting. Um, and, uh, that central 

Dr. Linda Bluestein: sensitization is one explanation. And when we think about injections, of course a lot of injections do involve local anesthetics, or we might be injecting local anesthetics before we do the injections.

And we know that there is data showing that people with hypermobile EDS are less sensitive to local anesthetics. In many cases, they might need a higher dose. It might not last as long. It might take longer, um, to onset. What do you observe in your practice? 

Tara Renton: Well, I do, I [00:41:00] lecture a lot around local anesthetic.

One of my favorite lectures is called Comfortably Numb, a bit of a Pink Floyd fan. And, um, it's very interesting that, um, dentistry again, is special in that we do really quite high tech difficult surgery in a difficult area in the mouth, on the most difficult nerve in the body. The trigeminal nerve is the one, the one nerve that protects all your eyes, your nose, your mouth, all the things that underpin our existence, our identity.

And if you have pain in this region, it's pretty horrible. It takes over your life. So, so the nerve is a really special nerve and it also has a direct feed into the limbic system. Unlike spinal nerves, which have a slightly more relay to the, to the, to the limbic system where it makes pain, immediately, makes you anxious, makes you worried about your, you know, your damage to your body.

The trigenal nerve has got like a, a straight arrow to the, to the most sensitive bit of the brain. So we dentist. Work on this area, on this nerve in patients that are awake paradoxically. [00:42:00] And that's down to history. You know, dentistry came from barber surgeons. Dentists actually invented general anesthetic, but the medics were the ones that walked away with a general anesthetic and actually said it's a really good idea to operate on patients that are asleep.

Now, how that never happened to dentistry, I dunno. But dentists are very reliant on local anesthesia. And as dentists, we are trained to do local anesthetic reasonably well, but we very often don't actually ask a patient if they're okay. There was a dental survey done in 2009, which shows that like 30% of patients had moderate to severe pain during their just routine dentistry.

And everyone who goes to the dentist is gonna expect pain because that's what they experience. So what we do as clinicians could definitely be better. And there was three groups of patients, the pregnant patients, the redhead, and the hypermobility patients are the ones that we know don't respond to local anesthetic very well.

And the hypermobility, the HSD and the ED patients are particularly really insensitive to, to local anesthetic. [00:43:00] So we have a, a real issue where we're not recognizing this in us, in our patients. So, and I, I think a lot of dentists don't, a, recognize that there's a significant proportion of patients that don't respond.

To local anesthetic, the same as everyone. So we, we know that if you are redhead, um, and uh, hyper hypermobile, when you have one of those deep injections, the inferior dental block injections, the one that goes in the back of your mouth with a long needle, uh, we know that actually dentists should be waiting 10 minutes for those, for those blocks to work.

Dr. Linda Bluestein: Mm. 

Tara Renton: But they don't, they start drilling and filling straight away. 

Dr. Linda Bluestein: Right? 

Tara Renton: And if you are one of those groups, you probably can take up to 20 minutes, 18 to 20 minutes to get the best pulpal anesthesia, the dental pulp, anesthesia, um, given by that injection. But what's really important is the inferior dental block injections that we give for a lot of dentistry are actually not great.

And there's a much better way of doing local anesthetic, which is [00:44:00] using articaine, which is a slightly stronger anesthetic just in the gums, Buckley, in the mandible. You just use infiltration for lidocaine in the maxilla. Uh, but you use arti, again, slightly stronger anesthetic, Buckley in the mandible with sometimes a lidocaine top-up lingually.

And you can do most dentistry just with infiltrations, and you get much better pulpal anesthesia, much, much better pain relief. So I spent hours of my life trying to persuade people to change the training in dentistry and actually use the strategies. So hopefully your patients can be educated. Now when they go and see the dentist, first of all, they ask for a mouth prop so they rest their joints when they're at the dentist.

And the second thing is don't. Don't have a a block injection unless you're having very complex prosdontics or root canal at the back of your mouth. Make sure the dentists are giving you infiltration dentistry because you'll have much less pain. It works much quicker and there's no studies yet in ED or uh, HSD patients, uh, or [00:45:00] pregnant patients, but.

The likelihood because the pulp plan sees so much better. We know that actually it's gonna work better. And there's just one really good study, um, uh, Schubert, I can share that reference with you. And he looked at around 900 people who were non-responsive anesthetic. And actually those with EDS, 33% of them did not respond to normal inferior dental block anesthesia, which is big, a big number.

And, and you know, often you are at the dentist and you say, actually that hurts. The dentist are rubbish. I've given you an injection now. Right, right. And, and, and often, you know, um, Ken Hargreaves, who's the king of local anesthesia, he's an endodontist pharmacologist in Texas, a great mentor of mine, great colleague of mine, he has been saying for years, you know.

You'd need to wait for an inferior dental block to work and actually if it doesn't work, it's probably not gonna work. By giving a, giving you another one, you need to do a different technique with a different anesthesia. So all these things could be very simplified down to giving injections in the buckle area of the mandible if you're having mandibular dentistry, the lower jaw [00:46:00] and just, and having just routine local anesthetic infiltrations in the maxilla and in the his but study it showed that actually Artane was a better of the local anesthetic for, for EDS and HHSD patients.

So, so it all fits in and that's, you know, there's, the evidence is not there, but common sense prevails that that would be the best way to manage those patients. 

Dr. Linda Bluestein: I love that. That, those are such great practical tips. So just to recap, because I feel like people are really gonna wanna write this down.

They're driving in a car, they're gonna pull over or they're gonna wanna listen to this part again. Um, so what you're saying is that when they go to the dentist, respectfully, of course, that they should ask for Artane, A-R-T-I-C-A-I-N-E. Yeah. A buckle. So, infiltration. Artane 

Tara Renton: infiltration. Artane. Yeah. So Artane works really well as infiltration dentistry.

You don't want the high concentration as a block because there's a, there's a increased risk of nerve injury. So you'd want to avoid those [00:47:00] deep block injections and ask for infiltration dentistry. And if they dunno what it is, send them to my website or get 'em to email me, and I will give them a quick swift introduction to infiltration dentistry.

But that's really, that's really, you know, for implants, if you're having implant work. Everyone uses infiltration dentistry to be, there's hardly any, anyone will give a block for that. So why do you give block for routine dentistry? It just doesn't make sense. Um, and if you do give a block, you need to wait longer.

Dr. Linda Bluestein: Thank you so much for that. That's really, really valuable. And the part about the, uh, we call it in the US a bite block is what you're talking about, right? For Yes. When they're working. Okay. Well, 

Tara Renton: it's, um, it's a, it's a bit like when you go, it's, I think a lots of people will think of one who flew over the Cuckoo's Nest.

It's one of those big bite guards you put, you put in that patient's mouth when they have a general anesthetic and you're doing dental work on them. 'cause it, you have to open them. So it's a bite block is probably the description. I think we're talking about the same thing. It's something that's about sort of two [00:48:00] fingers thick.

And you put between your teeth and you just relax open 

Dr. Linda Bluestein: on that, on that bite block. It's so interesting that you pointed that out because that is literally when my jaw went from being, you know, I had a, I did have a splint that I wore at night, but my TMD was completely manageable and I went and have a tooth worked on and it was the same dentist who had made my splint.

So I thought, well of course he knows that I have TMD 'cause he made my splint. I did not think to point out to him that I had TMD, they did not use a bite block. Um, I was literally, I've had two children. I was panting like I was having a baby. It was so painful. And that's when they finally put the bite block in.

And in hindsight, like I should have said something, I should have made sure that they remembered that I had preexisting problems with my jaw, and that is really when things flared up and became so much worse. So I'm really glad that you pointed that out, and I wanna come back to what you said about the trigeminal nerve, but I wanna kind of wrap some of this other stuff up first.

But if we can come [00:49:00] back to the trigeminal nerve, you made some very interesting comments about that as, as well. Mm-hmm. Okay. So speaking of flares, um, what I just, uh, said, for people who already have, uh, problems, they have jaw pain, um, they might have hypermobility, uh, what kind of strategies can they employ that might help prevent having a flare or having worsening of their symptoms?

Tara Renton: Mouth opening, prolonged mouth opening. Um, so dental appointments, general anesthetics singing, opera, singing wind instruments, chewing gum. Biting into apples, toffee, apples, burgers, just chop food up and just try and just soften the food as much as possible. Um, analgesic if you need them. But, but not opioids.

Opioids. I mean, America, you've had this horrible experience of using opioids routine for pain. Luckily in Europe we never did that. So Paracetamal and ibuprofen or acetaminophen is all you [00:50:00] need. And, uh, ibuprofen, it's all you need. They're the best possible painkillers, anti-inflammatory painkillers that you can use or use 'em together because they work synergistically.

They make each other better. So you take them at the same time if you can take both. So, so those are sort of simple things. Going back to what we were talking about interventions. I mean, if your jaw pain is not responding to the splints, the soft diet to ch changing behavior, um, and you've tried, um, you've tried your acupuncture, you've tried your physiotherapy, if it's not responding to that, then there is other things that we use for other chronic pains like migraine.

And it may be that you've got migraine that needs to be excluded, but it's, um, drugs like, um, tricyclic antidepressants, amitriptyline, some of the GABA drugs, some of those drugs might help with the pain if it's still debilitating. Um, and, and that those drugs deal with neurovascular and, and nerve pain, that just might help take down the, you know, the notch of the pain so you can actually [00:51:00] function daily better.

Dr. Linda Bluestein: And I do also want to point out when we're talking about, uh, no neuroplastic pain, neuropathic pain, um, mast cells are also involved in the maintenance and, uh, persistence of chronic pain. So people who have mast cell, um, instability, mast cell dysfunction are definitely, you know, at higher risk. And I've really found that treating the mast cell problems really helps with pain a a lot.

So 

Tara Renton: I'd love to talk about the other thing is, is gut health. So, so talking about, you know, your endogenous pain modulation system, the best source, if you can actually make your own drugs. So, you know, um, dopamine, serotonin, all those amazing drug, those chemical mediating pain things that we have in our downward pain modulation system.

They're made by healthy gut back bacteria. So you can really, by optimizing your gut health, you can maximize those pain modulating chemicals, you know, rather than taking drugs, [00:52:00] you can do that. All by yourself by massively improving. You've got your gut health and there's all that information, you know, available out there.

And it's on my, on my websites as well. 

Dr. Linda Bluestein: I'm glad you pointed that out. Yeah, I totally agree. I did not appreciate, before I really started digging into this, EDS uh, you know, an HSD, persistent pain, other problems like fatigue and orthostatic intolerance, whether they meet the criteria for POTS or not, um, and the mast cell problems at all these things that, uh, are co-occurring and how one of the common threads, you know, is, is the gut.

If you can work on that, that you can often improve at least some, some of those symptoms. So, I'm glad you pointed that out. I, I totally agree. Let's talk about Botox. Yeah, I have, I haven't had Botox. Oh, you haven't? I, I've had it for, for my jaw. I actually had it a couple of times for my, uh, crow's feet in the operating room because, uh, one of the ophthalmologists was in doing some injections, like, uh, behind the eyes, under anesthesia, and [00:53:00] he had leftover and he was like, does anybody want it?

And I'll, I'll just inject it and, you know. Yeah. One of the perks of being an anesthesiologist. And then you go back to talk to your next patient and you realize that you've got, you know, little marks here from, from getting, from getting Botox. Um, so what does the current evidence say about Botox for TMD and does it worsen joint instability?

Uh, 

Tara Renton: that's a really good question. I dunno the answer to the second question. Um, one of the issues, so the evidence is not strong enough really. I mean, it is something that is on the, on mentioned in the guidelines, but the evidence is, is again, equivocal like the splints. Um, my argument would be that I would, I would personally be very worried about having repeated, uh, on botulinum toxin, the proper name for it, Botox injections.

Um, because we are seeing patients with botulism now. Um, oh really? So, so you need to be really careful thinking about, you need to be really careful about whether this is [00:54:00] indicated or not. And I mean, certainly the highest evidence for botulinum toxin injections is for migraine. And a lot of the places you might inject in or around the TMD Ular joint, there are areas that come very close to the TMD that work for migraine.

And I would suspect that if your myo is TMD is responding to Botox injections, it's very likely that you've got a migraine, a main migraine component to your, to your, to your jaw pain. Um, I would be very worried about having intramuscular injections. Um. We know that the lanum toxin needs to be actually deposited near the nerve injuring at nerve endings, and it has to be taken up into the nerve and actually processed into, in the ganglia the cell bodies.

So by, by injecting actually into the muscle, I really dunno what you're achieving apart from necrotizing the muscles. So you might want that if you've got, um, you know, [00:55:00] Brad Pitt type, square jaw, whatever, and you want your, your soft tissue reduced. Um, but I would not be an advocate of that. And the evidence again, is, is, is poor.

But I would say that if you've got migraine and you've been through all the different mechanisms, the different types of drugs and different types of regimes to minimize your migraine, then botulinum toxin injections I would rec, you know, would be recommended. Um, I would not recommend them personally just for TMD unless you've got a erogenous TMD, which is related, probably mainly driven by the migraine.

And then it might be a good indication, but the evidence 

Dr. Linda Bluestein: is poor. If you could change one thing about how clinicians diagnose or treat TMD, what would that be? 

Tara Renton: Uh, I'll, I'll treat the, assess the patient holistically, look for migraines, look for mood disorders, assess how they're managing on a day-to-day basis and, and do common sense.

Reassure them, get the diagnosis right and, and do [00:56:00] reversible therapies. Starting with a step one, step two, step three ladder that we have in the, in the RCS guidelines. Very simple 

Dr. Linda Bluestein: strategies. And what are the key things that you want patients to know about their jaw pain? 

Tara Renton: Good question actually. Uh, that actually, um, assuming so the joint disorders classification excludes.

Neoplasia excludes trauma. Excludes pathology. So when we're talking about tds, we've already excluded all those things. But I would say to the patient, you know, if your pain is getting worse, your trismus is getting worse, or there are, uh, concerns that are that, that it's worsening. It's not just saying the same and it's not getting better, but it's actually worsening.

Then you need to revisit your clinician and get it reassessed. That would be probably one of my number one things. 'cause that's the first thing we exclude when we see the patients. The second thing is, I would say, is that you are not alone very [00:57:00] much like migraines, particularly myo is TMD. The muscle based, uh, jaw pain is really, really common and it's stress related, it's anxiety related, it's sleep deprived related.

It's all those things that we have. Unhealthy diet related. Um, we all those, those features that we are manageable within our as well. I'm terrible sleeper and I've never managed, but things in theory that you can manage and try and help yourself and manage those things outta the equation. So self understanding your condition, that's self-limiting.

It's, there's no pathology, there's no na nastiness going on that's deteriorating unless you've got arthritis of the joint. And that's different, you know, it's one of the joint based things, and we treat that with, with analgesics mainly, but it's not causing you more, more, more harm. It's about being cognizant that you have this condition, manage your stress, manage your migraines, other pains that you have and, and [00:58:00] just try and be reassured the fact that, you know, it's a common condition.

It happens commonly, but actually a lot of these factors that drive it can be mitigated and you really can minimize the impact on you on these conditions. And, you know, 40% disappear. So, you know, they, oh really? They're, there's self-limiting for a lot of patients. Yeah. They happen around stressful periods of your life.

They happen when you're not sleeping. So when those things are, are fixed, you know, it, it disappears much like, you know, migraine blood of migraine patients will tell you the same thing. 

Dr. Linda Bluestein: So I wanna come back to that because you said TMD at, at least this is what I heard you say. So, TMD refers to, uh, dysfunction of the temporomandibular joint.

I mean, by def it's temporomandibular dysfunction, but that's when you, but it excludes if there is pathology, uh, it, the trauma I totally understand. Um, but like in my case, I know that I have arthritis in my, you know, I did on, on plan X-ray. You [00:59:00] can see it, but my dentist pointed that out. So I guess, 'cause we were talking about imaging and how that's not always indicated.

But then I guess from a. Diagnostic standpoint. Now it is maybe sounding a little bit like it, like it is because you need to perhaps rule those things out because those are gonna be treated differently. 

Tara Renton: Yeah, I don't think you need an x-ray to confirm you've got arthritis of, of a joint. I don't think you have to have, if you've got really quite disabling or, or um, progressive arthritis, then yes, but actually I, you wouldn't, you wouldn't, I don't think, I dunno what the ath arthritis guidelines are worldwide, but I don't think that involves taking an x-ray of every single joint, right?

No, sure it won't. So, so, you know, I stick to my guns on the, on the imaging. Um, you know, the diagnosis is a, it's a, you palpate the muscles. The diagnosis is very simple. You take your jaw function questionnaire, you take your PPHQ for, for anxiety, depression, um, and then you palpate the masseter, the, the [01:00:00] temporals.

We used to have to palpate the medial terroror stick finger down the back patient's throat. It's no wonder the patient felt pain. It's horrible. We don't do that anymore. And basically ask the patient if they have pain during function and familiar pain when you palpate over the jaw joints, that's your diagnosis.

Once you've screened out all the other things like pathology, trauma, previous trauma, um, uh, and you know, you've got someone with widespread arthritis, then it's, it's very rarely affects the joint. Interesting. Me. But that's something that you will take as part of, you know, the history. I think that might be a possibility.

Dr. Linda Bluestein: So as part of the history, you would be asking if they have arthritis in other joints? 

Tara Renton: Absolutely. Absolutely. So some, something we haven't talked about is reactive arthritis, and I see, I've seen a lot of patients with that, and that's patients who've had a flu, recent flu or recent viral infection. And, you know, you forget to ask these questions, but just say, you know, have you had a recent, uh, viral, viral infection?

Or, or, you know. [01:01:00] Flu and they'll say, yeah, no, I have actually, and I, and I said, well, did you have joint pain in that? Yeah, yeah, I did. I had joint pain everywhere was the joint. That's that when the joint pain started in your joint. Yeah, no, that's, you know, and, and it was like six weeks ago, reactive arthritis is really common and we forget to ask about that.

And that again, is self-limiting usually. Um, it's very rare that will persist, but that's really important to, to ask about 

Dr. Linda Bluestein: as 

Tara Renton: well. 

Dr. Linda Bluestein: And I wonder if people with hypermobile EDS, if they're more prone to that, I know there, there are definitely lots of data showing that they're more prone to long COVID or persistent symptoms related to COVID infection.

Tara Renton: So tricky, isn't it? 

Dr. Linda Bluestein: Yeah, 

Tara Renton: definitely. 

Dr. Linda Bluestein: Poor pa, poor patients. Yeah. And so often they're, they're young and have so many years ahead of them that they could really, you know, be highly functional and enjoying life and Yeah, it is, it's very challenging. But that's why I do the podcast because I feel like there needs to be some way for people to learn little.

Little and big hacks, 'cause we're gonna get to the [01:02:00] hack in a minute. Um, but your hack about, you know, when you go to the dentist asking for Infiltrative Artane, um, you know, for, for the local is really, really huge. And, and the bite prop and, and the bite block or bite prop. Yes. Yes. And I did wanna, very quickly before we go to the hack, I almost forgot, um, the trigeminal nerve.

Uh, somebody had asked me before to talk about trigeminal neuralgia on the show, and it's something that we really have not talked about. So anything that you're willing to share more about the trigeminal nerve, what people, how people would know that this is something that's a problem for them and what they can do about it?

Tara Renton: I would, I would love to do a separate podcast just on oracal pain. Oh, okay. Because triderm neuralgia is the least likely diagnosis that we're gonna make. And I'm actually, I'm Lec, I'm lecturing the Association of British Neurologists on Wednesday. It's called Facial Pain. Trigeminal neuralgia. Trigeminal neuralgia affects between one and three and 100,000 patients.

It's incredibly rare. It's in older [01:03:00] patients, it's spontaneous onset, it's elicited pain. It's usually elicited extraorally around here. Sometimes it's in inside the mouth, which complicates it with people thinking they have too thick and they're gonna have treatment. But the trigema neuralgia is already there.

There's 18% in her in, in a hereditary rate, which is really interesting. If you're interested in reading more, Giorgio Chu is the lead Italian worldwide, um, team. And this I can, it's all on my website, my pet or facial pain website. It's a very interesting thing and it's the, oh, probably the one of the few conditions when we do diagnose it.

Um, and we need to make sure we diagnose it correctly. 'cause frequently patients with nerve injuries, post-traumatic neuropathy are misdiagnosed with it. Patients with migraine, patients with trigeminal, automic, Algeria, the cluster headache group, these patients are constantly misdiagnosed with the. Tri neuralgia.

Some of them even go and have, you know, microvascular decompression and brain surgery when they didn't have TN in the begin. So tns a [01:04:00] really interesting condition, very simple diagnosis. Very simple treatment structure used to say, wait until, wait until you don't tolerate the medications. We don't do that anymore.

Before you get an MRI scan, you look for neurovascular conflict, which gives you one type of trigeminal neuralgia, which is where cerebellar vein or artery is pressing on the root of the trigeminal nerve, where it comes outta the midbrain. You look for pathology space, occupying lesions, and in younger patients you look for demyelination things like multiple cirrhosis.

So your MRI scan is very specific. You want to exclude multiple cirrhosis 'cause or, uh, tri orofacial trigema neuralgia, one of the early presenting signs in ms. Uh, you want to exclude, um, neoplasia, and then you want to know if the patient's got a neurovascular conflict because long term, when the medications aren't working.

Pilots or HGV lorry drivers and cannot tolerate medication, they'll, they'll get fast tracked to microvascular decompression, which is a very effective [01:05:00] surgery. It's brain surgery with morbidity, 1% mortality, 1% meningitis, not nice, but it, it works very well for a lot of patients. But the other two groups are secondary trigeminal neuralgia, which is probably nerve injury for the most part.

And then there's idiopathic trigeminal neuralgia, which doesn't have the neurovascular conflict. No other answers, but they present in exactly the same way. And again, it's one of those conditions in the hereditary that it might be one affected by channelopathy. So the sodium channel channels that we know were involved in, in pain reception, that those families probably have a channelopathy, which is inherited and may contribute to developing this condition later in life.

Usually around 50, 60 years old. I think that covers it pretty well. Okay. But I would so love, I would so love to talk about things that happen much more commonly. You know, see so many patients with nerve injuries caused by wisdom, teeth, dental extractions, implants, local anesthetic, and you know, root canal.

[01:06:00] Um, we see a lot of patients with, um, migraine. If you have disc entrapment, which you mentioned in jaw joint, in the arthro arthralgia group, you can get a shooting pain sometimes with a disc flicks forward. And the only bit of the joint that's actually innovated is actually the capsule next to the ligaments on the outside.

So the inside of the joint is not innovated at all. So you might get a shooting pain there. And the other one is mealtime syndrome, where you've got a blockage in your submandibular gland or protic gland, and you get the shooting neuralgic pain when the gland tries to salivate and the blockage causes shooting pain.

So all these things we need to get rid of first before we diagnose the rarest or a facial pain condition. Um, and it's, it's, it's a horrible pain. It's very impactful, much like cluster headaches, uh, you know, can lead to suicidal ideation and patients just not coping very well. 

Dr. Linda Bluestein: This Yeah, no, that's really, really interesting and um, yeah, sounds absolutely awful.

The, uh, you may, it says a [01:07:00] mealtime pain, which is so interesting 'cause I was thinking about people also who have eagle syndrome, where the YLS are. Elongated, which does happen more frequently in people with EDS and can be bilateral. And, um, I have a patient who recently had surgery and had an excellent result from that.

Really? But she, yes. Excellent result. 

Tara Renton: Interesting. Mm-hmm. Mm-hmm. 

Dr. Linda Bluestein: But, but she said she has had some first, first bite syndrome, which I'd never heard of. Mm-hmm. Yeah. Do you know what that 

Tara Renton: is? Yeah. First bite syndrome is usually related to the, to blockage in the sali gland somewhere. Oh. So, uh, it may be if she had submandibular approach, maybe the gland has had a bit of a nudge or something, I dunno.

Mm-hmm. Um, uh, I dunno, they would've approached it, I would've thought in that region. So it may be that the saliva gland is, is a little unhappy at the 

Dr. Linda Bluestein: moment. Yeah. Yeah. Interesting. Well, thank you. Thank you for sharing that. Okay. So as you know, we end every episode with a hypermobility hack. Um, what hack do you have for us?

Tara Renton: Um, 

Dr. Linda Bluestein: I 

Tara Renton: guess, I guess be aware that you [01:08:00] don't respond to local anesthetic, um, and ask your dentist to use infiltration dentistry. Be aware that you are, you know, more likely to suffer from pain, unfortunately everywhere, including the orofacial region, but very easily preventable. Your jaw joint pain. If you're having prolonged dentistry, ask for a bite prop or bite bike, you know, bite prop so you can rest with your mouth open and not stress your joints.

Dr. Linda Bluestein: Okay, well I am so grateful to you for chatting with me today and of course, I would like you to share with everyone where they can learn more about you. 

Tara Renton: Yep. So my name's Professor Tara Renton, um, based at Kings College London. Um, I'm very patient-centered. I've got two websites. One is orofacial pain.org uk, the second, and that's for patients with Head and Neck Orofacial Pain.

And, and a lot of what we've talked about is, is there we are developing a special HDS ed page with Audrey's help and that will be updated at the end of this year, early next year when we [01:09:00] update the Oracal Pain website, second website's trigeminal nerve org uk, which is, uh, centered around prevention and management of patients with nerve injuries.

Um, and this is, it's so annoying 'cause these are preventable and they're, they're life changing for patients. It's, it's horrible, horrible. For them. Uh, I've got a web app that you've kindly completed, which is, uh, called Face your pain.org, and that's in its beta phase. Um, we don't have data protection in the states, so, um, you know, technically it's, um, it's, it's not covered by data protection, but uh, it's data protected in Europe and the uk, which I think probably have equally, uh, high standards for data protection.

Um, but if you're interested to find out, tells you about whether you might have sleep disorders, migraine mood disorders, um, catastrophization, hypervigilance. So all those things that might impact on your managing your own pain is, is really important. Um, and you get that fed fed back to you. Um, and yeah, I think that's [01:10:00] probably it.

I've got, yeah, my two virtual children, my web app. 

Dr. Linda Bluestein: Yep. That's, that's wonder. That's wonderful. And, and you mentioned about, um, you know, for people living with nerve injuries, and of course people like me who already have anxiety think, wait a minute, wait. Oh no, I, I don't want, I don't want a nerve injury. Is there anything that we can do to, uh, minimize the risk of that?

Um, 

Tara Renton: well, certainly most of the chronic post-surgical pain that was described by Seltz and KLI many years ago, you'll be familiar with that cup of, they, they, they did some great work and it, it shows that, you know, that the, the risk factors are anxiety, depression, sleep disorders, all those things we talked about.

You are more prone, uh, if you have, or if you have a neuropathic condition already and you have ED or HSD, you are more likely to be prone to, um, to chronic, uh, post-surgical neuropathic pain. So my one tip would be only do what's [01:11:00] necessary. And my motto is less is more. That's probably the hack. You know, don't, I've seen so many patients now having even very minimal, um, cosmetic procedures, um, and they're, they're ending up with neuropathic pain.

So, so only go, go for interventions, injections, surgery, if it's evidence-based and it's absolutely necessary, that would be number 

Dr. Linda Bluestein: one. Yeah, no, that's great. When, when I first finished my anesthesia residency, if I, you know, when, or, or when I was younger, even if I was offered a surgery for something, I always thought, oh, this is gonna fix it.

So I was very much, you know, in favor of, of any kind of surgical intervention. And now I'm like, surgery as a last resort for, for, for me, for my own body. And yeah, well, 

Tara Renton: cats and selfa we're going back 30 years published. So things like thoracotomy, um, uh, breast surgery, limb amputation, phantom limb pain is a neuro, is a nerve pain, neuropathic pain, that there were talk 35, 40% of patients.

You know, [01:12:00] chronic neuropathic pain after, after those procedures. Now obviously there are procedures you have to have, but actually we've changed. Now we know the other risk factors, not just the patient risk factors, but the other risk factors are minimal access. Hugely, hugely effective pain management. So even anesthetists like yourself are using local anesthetics now, which you never used to in the past because we're blocking that central sensitization so that you know when you're asleep you are also getting local anesthetic to minimize that central sensitization.

So there's some really good strategies of, you know, minimal access, minimum times surgery, minimal tissue damage, and And ma maximal pain management. Perioperative pain management. That's a good surgeon. We'll do that for you. They'll only do the surgery when it's necessary and they'll do all those factors.

They'll work with a good anesthetist. 

Dr. Linda Bluestein: Yeah, preemptive analgesia huge. Yeah, for sure. So, okay, well very good. Well thank you so much again. It was a pleasure talking with you and we will have to have you back to talk about oral facial pain 'cause [01:13:00] it sounds like there's a whole additional set of things that we could share with people that would be valuable.

Tara Renton: Very happy to deal. Linda's been an absolute honor. A pleasure. It's been lovely chatting to you. Thank you very much for invitation.

Dr. Linda Bluestein: Well, that was such a great conversation with Professor Tara Renton, and I can't wait to have her back to talk about oral facial pain because there are obviously so many different things that can cause pain in these regions, and I would encourage you to watch this episode on YouTube if you are able, because there were various different points where she was pointing to different parts of her face.

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