All posts by Mariela Padilla

About Mariela Padilla

Dr. Padilla obtained her DDS in 1989 at UCR, and in 1998 completed a Residency Program in Orofacial Pain at UCLA. In 2005, she obtained her Master’s Degree in Education and Curriculum Design. Dr. Padilla started her clinical practice as a general dentist in 1990, and then dedicated herself solely to Orofacial Pain and Temporomandibular Disorders. As an Assistant Director of Online Education at Herman Ostrow School of Dentistry of USC, she designs programs and academic experiences for working professionals, and contributes with learning innovation and teaching development.

Man holding his head in pain

CGRP: 4 Letters That Became a New Frontier in Pain Management

Man holding his head in pain

What Does CGRP Stand For?

Calcitonin gene-related peptide (CGRP) is a neuropeptide (neurotransmitter of the nervous system) discovered over 30 years ago. It has specific receptors located both centrally and in the periphery. CGRP is present in trigeminal neurons and is released into the cranial venous outflow in acute migraine and cluster headache attacks (1).

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Functions 

CGRP has several functions (2), such as:

  • Appetite-suppressant
  • Contributes to gastric acid secretion
  • Temperature homeostasis
  • Increases heart rate
  • Plays a role in the release of the pituitary hormones 
  • Highly potent vasodilator with protective mechanisms 
  • Wound healing

CGRP is primarily released from sensory nerves and thus is implicated in pain. Increased levels of CGRP have been reported in migraines, cluster headaches, and might as well be present in temporomandibular disorders (3).

Within the brain, CGRP increases with ischemia, injury, hyperthermia, and seizures, activating neuroprotective processes (4).

The role of CGRP in pain management is likely mediated by modulating nociception and sustaining neurogenic inflammation that leads to peripheral and central pain sensitization (for example in migraine) (5).

 

CGRP as a Target For Pain Management

The use of monoclonal antibodies against CGRP is a novel therapeutic strategy for the management of some painful conditions, such as migraine and cluster headache (6).

CGRP-related therapies were designed specifically to act on the trigeminal pain system, with little or no adverse effects. Two groups of medications are available.

  1. Small molecule CGRP receptor antagonists (gepants) for acute relief of migraine headache
  2. Monoclonal antibodies against CGRP (Eptinezumab, Fremanezumab, and Galcanezumab) or the CGRP receptor (Erenumab) to prevent migraine attacks (7).

Considering the comorbidity between migraine and TMD and the role of CGRP in the trigeminal pain system, CGRP receptor antagonists may have therapeutic efficacy in the treatment of other facial pain conditions. Understanding the pain mechanisms offers opportunities to develop therapeutic strategies with better chances to improve patient’s wellbeing (8).

 

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Sources

  1.  Edvinsson L. The Trigeminovascular Pathway: Role of CGRP and CGRP Receptors in Migraine. Headache. 2017 May; 57 Suppl 2:47-55. doi: 10.1111/head.13081. PMID: 28485848.
  2. Russell, F. A., King, R., Smillie, S. J., Kodji, X., & Brain, S. D. (2014). Calcitonin gene-related peptide: physiology and pathophysiology. Physiological reviews, 94(4), 1099–1142.
  3.  Yuan H, Spare NM, Silberstein SD. Targeting CGRP for the Prevention of Migraine and Cluster Headache: A Narrative Review. Headache. 2019 Jul; 59 Suppl 2:20-32. doi: 10.1111/head.13583. PMID: 31291020.
  4.  Borkum, JM. CGRP and Brain Functioning: Cautions for Migraine Treatment. Headache. 2019 Sep; 59(8): 1339-1357. doi: 10.1111/head.13591. Epub 2019 Jul 21. PMID: 31328279.
  5.  Yuan H, Lauritsen CG, Kaiser EA, Silberstein SD. CGRP Monoclonal Antibodies for Migraine: Rationale and Progress. BioDrugs. 2017 Dec;31(6):487-501. doi: 10.1007/s40259-017-0250-5. PMID: 29116598.
  6.  Carmine Belin A, Ran C, Edvinsson L. Calcitonin Gene-Related Peptide (CGRP) and Cluster Headache. Brain Sci. 2020 Jan 6;10(1): 30. doi: 10.3390/brainsci10010030. PMID: 31935868; PMCID: PMC7016902. 
  7. Akerman S, Romero-Reyes M. Preclinical studies investigating the neural mechanisms involved in the co-morbidity of migraine and temporomandibular disorders: the role of CGRP. Br J Pharmacol. 2020 Dec; 177(24): 5555-5568. doi: 10.1111/bph. 15263. Epub 2020 Oct 21. PMID: 32929719; PMCID: PMC7707098.
  8. Edvinsson L. Role of CGRP in Migraine. Handb Exp Pharmacol. 2019; 255: 121-130. doi: 10.1007/164_2018_201. PMID: 30725283.
Woman grabbing her neck in pain

3 Elements of General Neck Examination

Woman grabbing her neck in pain

The evaluation of the neck provides useful information for the dental practitioner by identifying conditions that might contribute with the oral health of the patient and the appropriate function of the masticatory system. At the same time, it constitutes a triage, which allows for a timely referral. There are three elements to consider in the general neck examination: history, clinical examination, and imaging.

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History

During the interview, the patient should be specifically asked about neck pain, mobility, sounds, and if there is history of any trauma in the head. An example is a whiplash injury produced during a motor vehicle accident. Positive responses might alert the clinician of the possibility of having a patient with cervical arthritis or muscle contractions, with limitations to position the head for dental treatment.

It is also useful to ask about persistent contraction or pain in the shoulders, to identify a patient with stress, who will require some modifications during the regular dental care, such as shorter appointments and behavioral techniques to reduce the anxiety.

Another good question during the examination is the size of the neck. Usually the patients will know that number for clothing purposes. This will allow the clinician to consider the possibility of sleep apnea (17 inches or more might be related with Obstructive Sleep Apnea).

 

Clinical Examination

A way to perform the evaluation is to start with neck movements and then address the neck by sections (anterior, lateral and posterior).

Neck Range of Motion

Ask the patient to gently bend forward, rotate the head, and side-bend to each side. Observe if the movements are symmetrical and if the range of motion is near normal parameters. Bending forward or cervical flexion is usually 70-80 degrees; cervical rotation might reach 90 degrees; and side-bending is usually 40-50 degrees). A restriction in the range of motion might indicate pain, muscle contraction, cervical nerve root impingement, or even a neurological condition and the patient has to be referred for proper diagnostic work-up.

Evaluation of the Anterior Section of the Neck

Start in the midline by assessing the thyroid gland, and by palpation identifying position, asymmetry, or enlargement. The patient might have a scar from a surgical procedure. Patients with thyroid problems are more prone to some oral diseases. Interdisciplinary care with the endocrinologist will be required in many cases.

The auscultation of the carotid artery is not a common practice in dentistry, but if palpation of the bifurcation area produces pain, one possible diagnosis is carotidynia, it might be the cause of facial neuralgic pain. In the anterior region, submental and supraclavicular nodes examination would identify tender or enlarge lymph nodes, requiring to rule out infections or neoplasms.

Evaluation of the lateral section of the neck

There are several neck muscles that closely relate to mandibular function and posture, such as the sternocleidomastoid (SCM) and the upper trapezius. During the lateral exam of the neck, palpation of those two muscles might be evidence of referral pain to the face (myofascial pain), being the source of pain that could be confused with odontalgia.

In between the SCM and trapezius, the scalene muscles are in close proximity with the brachial plexus, and some patients might experience a compression of that nerve bundle, producing numbness in the arm and lower pulse rate (thoracic outlet syndrome or TOS).

In the lateral region, the identification of tender or enlarged lymph nodes (cervical or
submandibular) will indicate the possibility of infections or even neoplastic
conditions requiring further evaluation.

An anatomical structure that can be evaluated by palpation is the atlas or first cervical vertebrae. The transverse process is located inferior to the ear between the angle of the mandible and the styloid process of the temporal bone. By asking the patient to move the jaw forward, the clinician can locate the structure and assess if it is symmetric and non-painful. In case of local or referred pain, a physician should assess the patient and physical therapy might be suggested.

Evaluation of the Posterior Section of the Neck

Several muscles can be palpated, starting in the nuchal line and moving the fingers downward to the seventh vertebrae. This group of muscles are post occipital and paracervical muscles and could refer pain to the temporal region. In the nuchal area, the occipital nerves emerge from the skull, and if the patient has an occipital neuralgia, tapping on that area produces pain which travels to the frontal region.

It is important to consider that if the patient has any condition in the posterior neck, the dental chair might need to be adjusted to prevent activation of pain as the patient receives dental care. As with the other regions, the evaluation of tender or enlarged lymph nodes should be performed.

 

Imaging

The prescription of any imaging for the neck is not in the scope of practice of dentistry; however, it is important to understand some of the options patients have.

For neck visualization, plain X-ray and ultrasound (US) are a good place to start. Plain images will provide information about general structure, presence of osteophytes, and the integrity of the intravertebral spaces. US will give information of soft tissues. It is the image of choice for salivary glands, thyroid gland, parathyroid, lymph nodes and cysts.

Advanced techniques include CT (usually with contrast) for cervical adenopathy, tumors, and any other condition where anatomic delineation is needed. An MRI will help to assess presence and extension of neurogenic tumors, vascular malformations, neck masses, and angiofibromas.

The dental professional has a great responsibility identifying alterations in the neck that might contribute with orofacial conditions or complicate dental provision.

 

Postgraduate Orofacial Pain and Oral Medicine Master’s Degree

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Female Dentist Holding a Needle Preparing for a TMJ Injection- Online Postgraduate Dentisty Degree Training in Orofacial Pain

How to Perform a TMJ Injection

Female Dentist Holding a Needle Preparing for a TMJ Injection- Online Postgraduate Dentisty Degree Training in Orofacial Pain

TMJ injections are performed with corticosteroid and anesthetic to produce a two-fold effect: one reduce inflammation with the corticosteroid (triamcinolone acetonide) and two produce anesthesia or pain relief using lidocaine 2% without epinephrine.  Corticosteriod is best used when swelling and pain are secondary to trauma, with acute OA flare ups, and DDNR cases. Continue reading How to Perform a TMJ Injection

Muscles of the Lower Jaw - How to Measure Muscle Tenderness to Diagnose Orofacial Pain

How to Measure Orofacial Pain With a Muscle Tenderness Exam

Muscles of the Lower Jaw - How to Measure Muscle Tenderness to Diagnose Orofacial Pain

In this article, we review ways to assess muscle tenderness and pain.  Common abnormalities of the masticatory muscle include injection induced myositis, myofascial taut band, trigger point, hypertrophy, spasms, etc.

Note: Prior to each procedure, introduce yourself to the patient, explain the purpose of the examination, obtain consent, and be sure to meet infectious control standards.

Relative Tenderness Assessment

With all muscles that you palpate there are two methods.  First is the relative tenderness assessment which is done using a standard anatomic location and a standard pressure level.  The locations are described below for each muscle.  The pressure to be used is 2 kg of pressure with one finger for 2 seconds.  While palpating, ask the patient to rate the pressure as none, mild, moderate or severe.

Note:  calibrate yourself periodically with a pressure algometer to make sure you are palpating with the right pressure on both hands.

Related Reading: Reliability and Usefulness of the Pressure Pain Threshold Measurement in Patients with Myofascial Pain

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Trigger Point Assessment

The second aspect of a muscle palpation assessment is to palpate across the muscle with your fingers to identify any taut bands.  This involves sliding the overlying skin back and forth across the muscle.  Taut bands will be evident if it is present and once you find the band, you move up and down the band applying firm pressure while asking the patient to report the most tender point in the band.  Once found, this point needs to be compressed for 5 seconds (with 2 kg pressure) to see if the pain radiates or refers.

Related Reading: TMJ Assessment: Jaw Range of Motion, Noise, and Tenderness

1. Deep Masseter Muscle Palpation

This site is anterior and inferior to the lateral condyle pole, posterior to the posterior edge of the superficial masseter, and beneath the zygomatic arch.  Palpate the deep masseter for tenderness using a none, mild, moderate or severe scale.

2. Superficial Masseter Muscle Palpation

This site is beneath the zygomatic arch and the muscle is angled back towards the angle of the mandible.  Palpate the superficial masseter for tenderness using a none, mild, moderate or severe scale.

3. Anterior Temporalis Muscle Palpation

The anterior temporalis muscle is best palpated at the hair line and opposite the eyebrow.  Palpate the anterior temporalis for tenderness using a none, mild, moderate or severe scale.

4. Posterior Temporalis Muscle Palpation 

This site is just above the pinna or the ear and its direction is posterior from the coronoid process.  Palpate the posterior temporalis for tenderness using a none, mild, moderate or severe scale.

Related Reading: How to Conduct a Cranial Nerve Examination

5. SCM (Sternocleidomastoid) Muscle Palpation

This site is from the manubrium of the sternum (sterno-) and the clavicle (cleido-), and has an insertion at the mastoid process of the temporal bone of the skull.  Palpate the sternocleidomastoid muscle for tenderness using a none, mild, moderate or severe scale.

6. Temporalis Muscle Tendon Palpation:

The temporalis muscle tendon is at the coronoid process just beneath the zygomatic process and is accessed by having the mouth open.  Palpate the temporalis muscle tendon for tenderness using a none, mild, moderate or severe scale.

7. Lateral Pterygoid Muscle Functional Exam

Test the lateral pterygoid muscle for proper function.  The lateral pterygoid muscle cannot be palpated but you can assess the function of this muscle by asking the patient to protrude the jaw.

8. Medial Pterygoid Palpation

Palpate the medial pterygoid muscle both intraorally and extraorally.   The origin of the medial pterygoid muscle is located on the inner surface of the pterygoid plate behind the maxilla.

Postgraduate Orofacial Pain and Oral Medicine Master’s Degree

Learn more about diagnosing, treating, and managing orofacial pain by enrolling in Herman Ostrow School of USC’s online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine.

 

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Woman with TMJ pain holds her jaw.

Closed Lock Mobilization: TMJ Exercises & Stretches

Woman with TMJ pain holds her jaw.

In this article, we’ll provice step-by-step TMJ exercises and treatments for Dentists and self-mobilization stretches for patients.

The main reason why a jaw locks closed is due to a derangement of the TM joint (disk displacement without reduction or DDNR).  It is also possible that the closed locking is due to trismus of the jaw closers.  The pain of closed locking is usually triggered with attempts to open wide, and at rest with the jaw closed it is much less painful. Continue reading Closed Lock Mobilization: TMJ Exercises & Stretches

Black and White Photo of a Woman with Braces Smiling

How to Perform an Occlusal Analysis

Black and White Photo of a Woman with Braces Smiling

Occlusion, simply defined, is how teeth meet when the lower and upper jaw come together.  Proper occlusion is necessary for eating, aesthetics, and disease prevention.  However, many factors can cause malocclusion including trauma and genetics.

Before we cover the Occlusal Analysis, let’s review a few definitions from our Dentist’s guide to Erosion, Attrition, Abrasion, and Abfraction.  If you’ve already read this article, feel free to skip ahead. Continue reading How to Perform an Occlusal Analysis

X-ray image showing articular fossa and condyle during a TMJ assessment

TMJ Assessment: Jaw Range of Motion, Noise, and Tenderness

X-ray image showing articular fossa and condyle during a TMJ assessment
X-ray image showing articular fossa and condyle.

For TMJ mobilization procedures read: Closed Lock Mobilization: TMJ Exercises & Stretches.

Jaw Range of Motion Assessment

Prior to the procedure, introduce yourself to the patient, explain the purpose of the examination, obtain consent, and be sure to meet infectious control standards. Continue reading TMJ Assessment: Jaw Range of Motion, Noise, and Tenderness

Female Dentist Performing a Lymph Node Examination on an Older Patient During a Dental Checkup

How to Perform a Lymph Node Examination

Lymph Node Examination

A lymph node evaluation should be included in all new patients as part of the oral cancer triage.  Below is a video showing the proper technique and a written explanation of what is expected from dentists when performing a lymph node and thyroid gland examination.

NOTE: Video recorded previous to COVID-19 pandemic.  The PPE does not reflect the actual requirements for patient care.

 

1. Anterior Cervical Lymph Node Examination

The lymph node examination is performed with circular motion, identifying pain, and swollen ganglia or induration.

For the anterior cervical lymph node exam, palpate the lymph nodes in the neck using circular motion over the underlying tissues in each area.  If a palpable node is located, describe it with detail (painful, hard, indurated).

2. Posterior Cervical Lymph Node Examination

With the tips of the fingers, move the ECM muscle to the front, and follow the posterior line with gentle but firm pressure.  Again, if a palpable node is located, describe it with detail (painful, hard, indurated).

3. Supraclavicular Lymph Node Examination

Palpate the supraclavicular lymph nodes, placing the fingers above the clavicle using firm pressure in small circular movements and feel for gland across the top and slightly behind this bone.

4. Submandibular Lymph Node Examination

Follow the lower border of the mandible with the tips of the finger.

Thyroid Gland Palpation

Inspect the thyroid gland from the front and from the side and then palpate the thyroid gland using both hands from front or behind the patient.  Examine the thyroid gland while having the patient swallow and by pushing the thyroid gland from one side while palpating with the other hand.

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