Melissa Rosenberger
Spring/Summer 2005
Case Study

Jaw Pain


34 year old female
8/5 Original complaint:  TMJ-for one year, always present, worse when wakes up, notices it a lot when gets home from work.  Also neck and shoulder pain since car accident 5 years ago, computer work aggravates it.  History of weekly occipital and temporal tension headaches.  Energy is low 4/10, gets 6-7 hours of sleep/night, some trouble falling asleep, vivid dreams of death or explosions, wakes up hot with mild night sweats 4-5/week, cold in the day, always thirsty prefers cold drinks, low appetite, tired after eat, food sits in stomach, gets spacey easily if under or overeat.  Some low back soreness, lots of stress in personal life (moving and breaking up with boyfriend), can’t get a deep breath, wants to sigh but can’t completely, 2BM/day tends to be loose.  28 day cycle, 4 days bleeding, dark red 1st two days, usually red, few nickel-sized clots, some premenstrual breast tenderness and emotional volatility, some cramping during period.  Some dizziness and positional vertigo that started after car accident happens 2x/day, some ear ringing.  Tongue moderately thick yellow coat, teeth marks, bloated, slightly pale, red tip  Pulse: thin, slightly wiry on right

Dx. St/Sp qi xu, Liver overacting on Sp, K yin xu, blood xu
Acu: GB 20, 21, St6, R17,12, Lr8, St 36, K6, SJ5
Herbs:  mei gui hua 6, zhi ke 6 he huan hua 8 shan zha 8 mai ya 8 chen pi 6 bai zhu 9 fu ling 9 zhi gan cao 4 zhi mu 9 huang bai 6

8/14 Digestion improved with herbs, BM more formed.  Tongue thick white, red tip, Pulse wiry and tense
Dx:  qi stagnation w/ Sp qi xu
Same herbs
Acu: cupping on back, GB 20, Lr3 Sp 9 St 36, LI 10, SJ 4

9/9 (My first treatment)  MC: TMJ and neck/shoulder pain, digestion still regular and formed.  Had bad cramps with period and mood changes.  Tongue is pale and broad, pulse rises between left 1st and 2nd positions. 
Dx:  Spleen xu with Stomach excess
Acu: Sp 6 St 36 St4-St6 GB 41 GB 2 SJ 5 GB 21
Herbs:  mei gui hua 6 zhi ke 6 he huan hua 8 shan zha 8 mai ya 8 chen pi 6 chao bai zhu 9 fu ling 9 zhi gan cao 4 zhi mu 9 huang lian 6

9/23:  TMJ slightly improved, neck and shoulders the same constant dull ache.  Appetite and digestion improved.
Continue with previous herbs, only took one bag d/t bitter taste

Continued for a few treatments similar to 9/23

11/4 Jaw tension worse, waking up frequently at night, some digestive complaints upset stomach after eating, some gas and bloating, some loose stool, bad cramps with period (ran in rain and was cold).  Tongue puffy with scallops and yellow coat in back, pulse week, Stomach position excess, Kidney positions weak
Dx.  K deficiency (meridian therapy) with yangming heat
Acu:  St 44 St 37 LI 11 K 3
Formula:  Bai Hu jia Ren Shen Tang:  shi gao 12, zhi mu 9 zhi gan cao 3 ren shen 6 shan yao 9, 1 bag/2 days

12/9 Jaw pain mostly gone, occasional mild ache, neck and shoulders also much reduced. 

TCM view of Facial Pain

Because the face is a place where all the yang channels meet, facial pain can be caused by disturbance in any of these channels.  Other common causes are invasion by external factors, flaring up of Liver-fire, accumulation of heat in the yang ming organs, wind-phlegm in the channels, deficiency of qi, or stagnation of qi and blood. 

Pattern Differentiation and Treatment

Invasion of wind heat:  facial pain with burning sensation, or prickling sensation, or sharp pain, constant pain, redness of the face, sweating, aggravation of pain by exposure to warmth, alleviation of pain by cold, thirst, fever, deep yellow urine, red tip to tongue, thin yellow coat, superficial rapid pulse.
Herbs: Xiong Zhi Shi Gao Tang (chuan xiong, bai zhi, shi gao, sang ye, ju hua, jin ying hua, man jing zi, cang er zi, sheng di huang
Acupuncture:  LI-4, LI-11, SJ-5, St-6, St-7, GB-20

Invasion of toxic heat: acute facial pain, redness, swelling and burning feeling, pus on the face, itching, fever, thirst, constipation, deep yellow urine, restlessness, poor appetite, red tongue with yellow and dry coat, rapid wiry pulse.
Herbs: Pu Ji Xiao Du Yin (huang qin, huang lian, xuan shen, zhi zi, ban lan gen, lian qiao, ma bo, niu bang zi, bo he, jiang can, sheng ma, gan cao, da qing ye, zhe bei mu
Acupuncture: LI-2, LI-4, LI-11, St-5, St-7, St-36, St-42, St-44

Invasion of wind-cold:  sharp pain of the face with spasm, aggravation of pain with exposure to cold, alleviation of pain with warmth, purplish or blue hue to face, thin and white tongue coat, superficial and tight pulse.
Herbs:  Chuan Xion Cha Tiao San (chuan xiong, jing jie, fang feng, bai zhi, yan hu suo, man jing zi, dang gui, xi xin, gan cao, qiang huo)
Acupuncture:  Lu-7, LI-4, SJ-5, GB-20, St-7, SI-18

Flaring up of Liver-fire: painful face with burning sensation, aggravation of pain with emotional upset, restless, irritability, fullness in chest, insomnia, headache, bitter taste, constipation, red tongue with yellow coat, wiry rapid pulse.
Herbs:  Long Dan Xie Gan Tang (long dan cao, huang qin, zhi zi, ze xie, mu tong, xiao ku cao, dang gui, sheng di, sang ye
Acupuncture: LI-4, Lr-3, Lr-2, Lr-8, Du-20, GB-2, GB-20, GB-43

Excess heat in the yang ming channels:  gradual occurrence of pain, hot feeling in face, toothache, headache, thirst, constipation, a lot of hunger, bad breath, red tongue with yellow dry coat, rapid and forceful pulse.
Herbs: Liang Ge San (da huang, mang xiao, gan cao, zhi zi, huang qin, lian qiao, bo he, sang ye, ju hua, bai zhi)
Acupuncture: St-3, St-6, St-7, St-34, St-44, LI-4, LI-11

Accumulation of wind-phlegm in channels: intermittent facial pain, facial spasm, mostly on one side of face, facial tic, aggravation by emotions, facial numbness, thin white and greasy coat, wiry and slippery pulse.
Herbs: Qian Zheng San (bai fu zi, zhi ban xia, gui zhi, dan nan xing, chuan xiong, bai zhi)
Acupuncture: Lr-3, Lr-5, Lr-6, LI-4, GB-3, GB-20, St-40, Sp-6

Qi deficiency: persistent facial pain with heavy sensation, aggravated by fatigue, pale complexion, facial edema, poor appetite, loose stool, shortness of breath, aversion to cold, spontaneous sweating, low voice, pale tongue with thin white greasy coat, thready and weak pulse.
Herbs: Bu Zhong Yi Qi Tang (huang qi, shan yao, huang jing, gan cao, dang shen, dang gui, chen pi, sheng ma, chai hu, bai zhu)
Acupuncture:  St-36, Sp-6, R-6 with moxa, Du-20, local face points

Stagnation of qi and blood:  long duration of pain in a fixed location, intermittent stabbing pain, aggravation of pain at night, purplish color to face, purplish tongue with thin coat, wiry choppy pulse.
Herbs: Tong Qiao Huo Xue Tang (chuan xiong, chi shao, dang gui, dan shen, hong hua, bai zhi, xiang fu, qing pi, zhi qiao)
Acupuncture: LI-4, Lr-3, Sp-6, St-3, St-6, St-7, St-40, SI-18




Western Medical View of Temporomandibular Joint Syndrome (TJS) or Temporomandibular Disorder (TMD)

TMD is the most common cause of facial pain after toothache.  There is no clear definition of the disorder. The Merck Manual states that temporomandibular disorder is “pain the the jaw and face, often in or around the temporomandibular joint, including the masticatory and other muscles, fascia, or a combination of areas.”  It can be classified broadly as either 1) TMD secondary to myofacial pain and dysfunction (MPD), or 2) secondary to true articular disease of the joint.  The two types can be present at the same time.  MPD is the most common presentation, it is associated with pain without pathological changes of the joint as seen on x-ray, it is characterized by a polyetiological nature and is often associated with bruxism and jaw clenching in a stressed and anxious person. 
True articular disease is from disk displacement, chronic recurrent dislocations, degenerative joint disorders, systemic arthritic conditions, ankylosis, infections, and neoplasia.

Pathophysiology: In MPD the symptomatology (pain, tenderness, spasm of mastication muscles), is due to muscular hyperactivity and dysfunction due to malocclusion of variable degree and duration.  Psychological factors like stress and anxiety have been recognized as important etiological factors.  In articular disease the most common cause is disk displacement and there will be crepitus.

Frequency:  TMD is commonly seen in primary care and dentistry, and at any given time more than 10 million people in the United States can be affected.  It primarily affects women in a 4:2 female/male ratio, and the highest incidence is among women aged 20-40 years. 

Symptoms:  Pain is usually periauricular, associated with chewing, and may radiate to the head but is not like a headache.  It is usually unilateral when of articular origin, except in rheumatoid arthritis.  In MPD the pain may be associated with a history of bruxism, jaw clenching, stress, and anxiety, the pain may be more severe during periods of increased stress. Crepitus is often present, but does not itself indicate TMD or a predisposition for TMD. There can be limited jaw opening and locking episodes when the mandibular condyle dislocates anteriorly in front of the articular eminence.  Headaches can be triggered from TMD and tend to be severe in nature. 
Other symptoms include otalgia, neck pain and/or stiffness, shoulder pain, and dizziness.  A third of patients have a history of psychiatric problems.  There may also be a history of facial trauma, systemic arthritic disease, and recurrent dislocation. 

Causes:  MPD is polyetiological and includes malocclusion, jaw clenching, bruxism, personality disorders, increased pain sensitivity, and stress and anxiety.  Patients with psychological issues tend to score high on obsessive-compulsive scale, have increased levels of disease conviction, and are less likely to deny the existence of problems in their lives.  TMD is caused by disk displacement, other etiological factors include DJD, RA, ankylosis, dislocation, infection, neoplasia, and congenital anomalies.  Other problems to be considered:  carotidynia, dental infections, jaw myotonia, otic infections, paratrigeminal syndrome, and styloid process syndrome.

Tests:
Lab Work:  Blood work should be done if systemic illness is a suspected cause.  CBC checks for infection, rheumatoid factor, ESR, antinuclear antibody, and other specific antibodies are checked if RA, temporal arteritis, or a connective tissue disorder is suspected.
Uric acid is checked for gout. 

Imaging studies:  Conventional radiography is most common.  MRI should be run if there is a suspected articular or meniscal pathology and surgery is being considered, or in the case of traumatic TMD. 

Medical treatment:  Most TMDs are self-limiting and do not get worse. Simple treatment involves self-care practices and muscle rehabilitation.  NSAIDs are used on a short-term basis. 
Treatment of chronic TMD is best managed by a team approach including PCP, dentist, physiotherapist, and psychologist.  Treatment modalities include self care practices, medication, physical therapy, splints, counseling, relaxation techniques, biofeedback, hypnotherapy, acupuncture, and arthrocentesis.

Medications:
Ibuprofen and naproxen are commonly used NSAIDs.  They should not be taken for more than 2-4 weeks.
Narcotics are reserved for patients with sever acute pain and should not be used for more than 10-14 days.
Muscle relaxants include diazepam, methocarbamol, and cyclobenzaprine.  Side effects include sedation, depression, and addiction.
Tricyclic antidepressants have been used for chronic painful conditions, they act by inhibiting pain transmission and may also reduce nighttime bruxism.  Amitriptyline and nortriptyline are the most common ones used. 
Night guards, bruxism appliances, or orthotics are used, or autorepositional splints.

Surgical Care:
Arthrocentesis
Arthroscopic surgery

Self-care: Includes eating a soft diet with gradual progression to a normal diet over 6-8 weeks, avoiding large bites and clenching of teeth, keeping jaw relaxed, yawning against pressure, massage, use of moist heat, avoiding cradling the phone between the ear and shoulder, good sleep posture with adequate neck support, and passive or active range of motion exercises. 

Discussion


With this patient (I’ll call her Stella) it was easy to stay focused on the Liver qi constraint/Spleen deficiency aspects of her pattern, but over time that treatment strategy was only marginally effective.  We had reached a plateau in her treatment and she had to keep coming in to get treatments for any sort of sustained improvement.  So I decided to take a more aggressive course of treatment and prescribe her Ren Shen Bai Hu Tang even though signs of Stomach heat were not evident and it seemed counterintuitive to use a form of Bai Hu Tang in a patient with Spleen qi deficiency.  The only possible signs of Stomach channel  heat were her preference for cool beverages and some redness in the front half of her tongue.  I was concerned that the use of shi gao and zhi mu might exacerbate her Spleen deficiency and cause a relapse in digestive trouble for her (her digestive symptoms had responded well to the initial treatments), but since there was a chance that the stagnation in her middle jiao was generating heat and that clearing heat from the Stomach channel might be the key to resolving her jaw tension we decided to pursue that course of treatment in the short-term and see how she responded.  If she had continued to come to clinic for treatments we probably would have continued to strengthen her middle jiao since Spleen deficiency was an underlying factor in the generation of the Stomach heat and we would want to prevent reoccurrence of the symptoms. 

This is a good example of a case in which a slight shift in perspective is necessary to achieve lasting treatment results.  It was also important to more aggressively target the branch aspect of this pattern (the Stomach heat) than the root (Spleen deficiency with food stagnation) in order to resolve the symptoms.  This case is also a good example about how you can treat mechanistically even when overt symptoms are not present.  Once we decided that the pain may be mechanistically from Stomach heat we followed that treatment course even without the usual symptom pattern that is recommended for the use of Bai Hu Tang. 

From a western perspective Stella fits the demographic for a likely TMJ patient.  She experiences high stress in her life, has a tendency towards anxiety, grinds her teeth at night, and is female.  She had been given a night guard to protect her teeth from the grinding, but it had not made a major difference in her experience of jaw pain.  While psychoemotional factors may have been taken into account via her MD at some point, we found that focusing on that aspect of her presentation as Liver qi constraint was not ultimately the most useful. 


Abstracts
 
Treatment by Electro-Acupuncture: Chronic TMJ Dysfunction
by Zhen-ming Tian
Journal of Chinese Medicine, Number 56, January 1998

The authors treated 68 cases of TMJ with electroacupuncture.  LI-4 and St-7 were needled bilaterally 3-4 cm deep with strong stimulation.  Electroacupunture was applied between these points for 10-20 minutes for 5 treatment sessions, 2 days between each session.  After treatment 61.8% had  complete symptom alleviation, 27.9% had no pain but still restricted jaw movement, and 10.3% showed no improvement. 


Temporomandibular joint related painless symptoms, orofacial pain, neck pain, headache, and psychosocial factors among non-patients.
Acta Odontologica Scandinavia. August 2003; 61(4):217-222.

The aims of this study were to assess the prevalence of TMJ painless symptoms, orofacial pain, neck pain, and headache in a Finnish working population to evaluate the association of the symptoms with psychosocial factors.  They found that frequent TMJ-related symptoms were found in 10% of 1339 subjects, orofacial pain was reported in 7%, neck pain in 39%, and headache in 15%.  Females reported symptoms more frequently than males.  Frequent pain and self-reported TMJ-related symptoms were significantly associated with stress, depression, and somatization.  These painful conditions seemed to be more associated with work-related psychosocial factors than with the type of work itself.







Using acupressure in conjunction with Dian Sai method for jaw dislocation.
Journal of Sichuan Traditional Chinese Medicine, Vol. 19, No.12, 2001.

The authors used acupressure on the points jia che, xia guan, and ting hui before performing a jaw relocation manipulation technique.  The points were used to increase jaw muscle and joint flexibility before the manipulation was performed.  Dian Sai refers to the process of having the patients chew lightly on a cotton ball with their back teeth to induce jaw flexibility pre-adjustment.  This technique was very successful, only one patient out of 30 did not respond fully to treatment. 


Other Biographical Sources


e-medicine.com:  Temporomandibular Joint Syndrome

Peilin, Sun Ed.  The Treatment of Pain with Chinese Herbs and Acupuncture.  Chapter 11: Facial Pain.  Harcourt Publishers Limited, 2002. 

The Merck Manual, 17th edition, Merck Research Laboratories, 1999.