Editorial:

DRY BONES

 

Many of you are old enough to remember the lyrics of an old song that came out many years ago called Dry Bones.  The lyrics taught us: “the back bone is connected to the neck bone, the neck bone is connected to the head bone, etc.”  The song went on and on and on, relating every part of the skeletal structure to the other. Although the song was written tongue in cheek, for those of us who have been involved in the treatment of craniofacial pain and temporomandibular disorders for any length of time, the lyrics do still ring surprisingly true.

 

Although bureaucrats and state boards have compartmentalized the human body into neat segments, each to be supervised and managed by a different provider in our healthcare system, our creator’s plan for us was not so simplistic.  Those of us who have taken the time to critically observe now know that modifications in the craniomandibular relationship can effect changes in the cranio-cervical relationship and, of course, vise versa.  We also know that the cranio-cervical posture can effect the posture of the spinal column, and that there is a relationship between cervical postural and lumbar postural. These facts have been accepted in the Chiropractic and Osteopathic professions for years. 

 

Researchers, authors and observers like Ricketts, Gelb, Rocobado and so many others have demonstrated that we are not so compartmentalized as our healthcare overlords would have us believe.  As a result, when we, as practitioners, are treating the chronic head and neck pain patient, we are often confronted with factors outside of what we may be legitimately allowed, or for that matter trained, to treat.

 

In the Mini Residency of the American Academy of Craniofacial Pain our students are constantly made aware of, and receive training in, areas of the human anatomy and physiology as it relates to craniofacial pain disorders.  In addition to studying maladies of the temporomandibular joint, neuropathic, neurovascular pain and muscle disorders, we also look at the fact that postural and biomechanical factors may play a role in the genesis of craniofacial pain. 

 

We stress to our students that, although they are not necessarily trained to treat some of these issues, they must be cognizant of their influence on the body lest the patient receive only partial treatment, and thereby receive only marginal improvement in their quality of life.  As the quarterback for the craniofacial pain team, it is our responsibility to be aware of the fact that our colleagues in allied disciplines may have a direct role to play in helping us to achieve what we and our patients desire. 

 

When dealing with musculoskeletal issues in my own practice, I constantly work with physical therapists who help me deal with the patient’s postural and gait issues as well as general musculoskeletal alignment. I know very well that my success in treating the patient’s temporomandibular disorder can be directly and positively influenced by the physical therapist’s treatment. By combining treatments in a well-organized, systematized approach, I know that the patient has a much better chance at a positive outcome than if I were acting as the sole clinician. 

 

 

My chiropractic colleagues are frequently called upon to help promote proper spinal alignment. I have often found that spinal adjustments are more successful when I have provided the chiropractor with a stable maxillo-mandibular relationship (and my appliance therapy benefits) by having the patient stabilized in their cervical/spinal relationship.

 

Similarly, a podiatrist  may have a direct relationship on postural considerations as they reflect themselves through the entire kinetic chain. 

 

Have you ever worked with a massage therapists trained in neuromuscular massage?  They can be a valuable ally in managing musculoskeletal pain. Weldon Bell has stated that after eliminating pain of dental/alveolar origin, pain of muscular origin is the most common reason for head and neck discomfort.

 

For those of us involved with Craniofacial Pain Disorders, we constantly encounter not only temporomandibular disorders or problems affecting the musculoskeletal system, but also frequently encounter patients with neuropathic or neurovascular pain disorders. A working relationship with a neurologist that understands our area of expertise is a great asset. Locate a neurologist or two in your area and get to know them. They can be valuable allies, not only to refer your own patient’s to, but to receive referrals from as well. Be proactive and make the initial contact.

 

Do you screen for otologic problems when patients complain of ear or pre-auricular pain?  I have several excellent otolaryngologists that I routinely work with. A simple look into the external auditory meatus with an otoscope should be routine. It’s pretty embarrassing to find out (and potentially damaging to one’s reputation) that the “TMJ problem” you diagnosed is in fact something as obvious as an ear infection. I cannot tell you how many otologic issues I have found in my career. An intelligent and well-founded referral Rolodex definitely sets you above the rank and file.

 

I also find that my ENT physicians are one of my best referral sources. This is because they understand what I do because I have gotten to know them and educate them in what I do.  Once again I must stress: get out there and make those crucial relationships.

 

And don’t forget the psychosocial component. You cannot separate the mind form the body. Chronic pain patients may benefit from counseling or stress management. Pain can play mean tricks on the patient’s perception of their problem.

 

I hope you are dictating your examination summaries or are using one of the excellent computer generating letter systems. Not only should the referring health care professional receive a copy, but other specialists they may have seen should be included.  And don’t forget the primary care physician.  They should be kept in the loop and can also be an excellent source of referrals. Network, network, network!   Surround yourself with the best practitioners you can find.  Earn their respect.  Utilize their expertise so that they will utilize yours.

 

Just as no man or woman is an island, the same goes for practitioners.  The day of the “cottage industry health care office” is long past. Our patients present us with complex pain problems, often which are multifactoral and cannot be managed by one individual alone.  It is imperative that as we evaluate our patients, we understand the necessity for working in a multidisciplinary theater.   More now than ever, in this Information Age, we have the ability call upon specialists from a variety of disciplines to better aid us in healing our patients... so long as we are wise enough to acknowledge that we alone do not know everything.   

 

At a time when medicine has become more complex and compartmentalized than ever, it is critical that we not forget this one simple fact: we all have our limitations.  By so doing, we will better serve our patients, better serve our profession, and help to elevate the area of craniofacial pain to the respected specialty that it deserves. 

 

After all, we are all in this together. 

 

Gerald J. Murphy, B.S., D.D.S.

Grand Island, NE 68803