* What is the trigger point
When a patient complains of pain in a tooth and the clinician can not find the local cause of the problem, be aware that there can be such a pain without them having its origin in the tooth structure. Dental pain (toothache) of dental origin, may come from muscle or nerve structures: The most common is the muscle, usually produced by so-called trigger points. The main muscles of the head and neck that occur in trigger points and referred pain to the teeth are the masseter, temporal and posterior belly of digastric. We can also find them in muscle Sternocleidomastoid and Trapezius Occipital, reflecting the pain to other areas of the face.
The pain of myofascial trigger points was first described by Travell and Simons in 1952. According to Han SC Harrison are more prevalent in women than in men.
The trigger points are also in the magazine called “Dental Clinics of North America” as “trigger points mioaponeurticos”.
TRIGGER is the point
It is highly localized in muscle tissue or tendon insertions in, which can be felt as hard bands (hypersensitive) that cause pain, having this feature be of deep, constant and can produce effects of excitation central nervous system level, often causing referred pain to other areas (teeth and areas of the face) depending on the location of the trigger point. Not determined the exact etiology of the trigger points. Research is ongoing to try to determine the possible causes of the trigger points and the mechanisms involved. Some authors like Travell and Simons believe that trigger points can be activated by overload, stress, fatigue, direct trauma and cooling can also be activated indirectly by other trigger points, visceral disease, arthritic joints and stress.
A trigger point is a very limited region in which only relatively few motor units contract. If all of contracting a muscle, it occurs naturally in length shortening (myospasm).
* The patient’s chief complaint is often referred pain, that is in a different zone of the actual source of the pain (trigger points). In many cases, patients may be aware only of referred pain and not at all identify the trigger points that are the real source of the pain.
* The trigger point can be found in active or latent, in the active state produces referred pain and the longer latency sensitive to palpation and therefore does not produce referred pain.
* The deep painful stimuli from the trigger points creates effects on the central nervous system, which can lead to tearing, or clinical signs of dryness of the eye (unilateral).
* The three main masticatory muscles that cause pain referred to the dental structures are:
* Temporary usually just refer pain to the maxillary teeth, but can do so at the earlier or later depending on the location of the trigger point.
* The Masseter makes it so only the back teeth, but may refer to the maxillary or mandibular according to the location of that point.
* The above only refers Digastric pain at mandibular anterior teeth.
* Occipital Muscles, Trapezius and Sternocleidomastoid usually have frequently referred pain by the patient as a tension headache.
* The trigger point is a symptom that may be present alone or may be part of a group of clinical manifestations such as headache, dental wear facets, hearing disorders, muscle spasms, etc.., Forming the myofascial pain dysfunction syndrome. The trigger point may or may not be present in this syndrome.p align = “center”>
The key to identifying dental pain is referred to the local provocation a painful tooth does not increase symptoms. That is, the heat, cold and / or Biting not increase or modify the pain. However, the local provocation active trigger point increase dental symptoms. When the clinical suspicion of referred pain in a tooth, a local anesthetic blockade of the same and / or muscle is useful to confirm the diagnosis. The infiltration of a local anesthetic around the painful tooth will not reduce the pain, but the lock with the anesthetic trigger point cushion this point and eliminate the toothache.
The definitive treatment is effective in the elimination of trigger points in the muscle involved. The trigger points can be treated with the technique of “spray and stretch” that is to apply a spray fluoromethyl with stretching of the muscles involved (includes massage or low intensity ultrasound). Injection techniques with local anesthetics without vasoconstrictors (or needle) followed by relaxation, may also be useful. Also be used ischemic compression, which is a firm digital pressure applied to the trigger point followed by a stretch with a specific range of movement. They have also been used TENS (transcutaneous electrical nerve stimulation) and Iontophoresis which is a technology proposed for use to carry an electrical gradient ionic form of medication, usually corticosteroids in tissue. The use of these treatment techniques must be performed by specifically trained for it.
The clinician should be aware that when a patient comes to pain (either dental or headache), this does not always have its local and referred pain can be a result of a trigger point, so it should make a correct clinical examination in order to detect the source of pain. You must have a broad view of the problem in question, and particularly for us as dentists, go beyond the tooth and see the patient as a whole. Having determined that the source of pain is a trigger point, the clinician must remember that treatment should be aimed at eliminating muscular disorder and the treatment of painful tooth.
Poster presented at the II Metropolitan Dental Congress and Second Congress of the Caribbean in May 1999, awarded the 2nd place in the clinical area. (Figs. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12).
1. Attanasio, Ronald. “Dental Clinics of North America. Orofacial Pain, related disorders”. 1997.
2. Murfhy, GJ Physical Medicine Modalities and tigger point injections in the management of temporomandibular disorders and Assessing treatment outcome. Oral Med Oral Pathol Oral Srg Oral Radiol Endod Jan, 83 (1): 118-22, 1997.
3. Okeson, Jeffrey P., “Occlusion and temporomandibular disorders” Third Edition. Mosby / Doyma Books. 1995.
4. Okeson, Jeffrey. DMD. “Orofacial Pain. Guidelines for Assessment, Diagnosis and Management”. Quintessence books. 1996.
5. David G. Simons MD, Travel, Janet G., MD, Simons, Lois S, PI, “Myofascial Pain and Dysfunction. The Trigger Point Manual”. Volume 1. Upper Half of Body. Second Edition. 1992.
Dr. Patricia Hernandez.
Assistant Professor of the Department of Anatomy and Dental Service Coordinator craniomandibular disorders. UCV.
Dr. Claudia Garcia.
Collaborator adhonorem (for scale) Alterations Service craniomandibular 1999 and currently Post-graduate student of aesthetics. UCV.
Nataly Dr. Akhras.
Current adhonorem Collaborator (for scale) Service craniomandibular disorders. UCV.
Dr. Andres Azpurua.
Senior Service craniomandibular disorders through July 2000.
Dr. Jose Hernandez.
Senior Service craniomandibular disorders until May 2000.
Dr. Dayana Hernandez.
Collaborator (by scale) in the Department of Operative.