Progress notes

The practice of managing pain

The most important thing Dr. Steve Bender does for his patients is let them talk. By the time they come to see him, they’re frustrated, searching for answers and often out thousands of dollars for treatment that didn’t relieve their symptoms.

Bender ’86 knows this experience well. After suffering from head and neck pain, his own quest for answers led him to a niche within dentistry: pain management for the head, neck, temporomandibular joint and oral cavity. Since 2001, Bender’s Plano, Texas, practice remains solely dedicated to patients suffering from these conditions.

A clinical assistant professor at Texas A&M University Baylor College of Dentistry, Bender is used to teaching TMJ anatomy, occlusion and pain management. A new venture with the periodontics department and Dr. Terry Rees, director of stomatology, potentially deepens the learning experience for students and residents. For a few hours every other week, Bender sits down in a clinic operatory with patients to hear their concerns, perform an examination and come up with a treatment plan, which is often surprisingly conservative and noninvasive. The appointments are not short — he usually sees just one or two patients during each campus visit.

With time, Bender would like to see residents rotate through the clinic, and as the initiative expands, patient referrals could come from the community in addition to TAMBCD. Now he explains what led him to the practice of pain management, the systematic approach to diagnosis and the mindset needed to treat conditions that can be described but not seen.

NewsStand: How did you become a head, face and temporomandibular joint pain expert? What would you recommend to a fellow dentist looking to pursue this niche within the profession?

Bender: I get a little nervous with the term expert! The more I learn about pain of the head and face, the more I discover how much we really do not know about these maladies. I developed an early interest in temporomandibular disorders and headaches as a result of having these issues myself. After taking every continuing education program I could find, I discovered that there were a few university-based, postgraduate programs in orofacial pain. Dr. Henry Gremillion, who is now the dean at Louisiana State University’s School of Dentistry, was the director of the orofacial pain program at the University of Florida at that time. He graciously allowed me to become an “unofficial fellow,” which involved spending a week every month at UF’s pain center during a two-year period. That was about 13 years ago. After that, I sold my restorative practice and began practicing strictly orofacial pain. To the dentist who desires to pursue this area of practice, I would recommend university-based training programs. There is so much information being taught that lacks scientific evidence to support it. Most university training will consist of evidence-based teaching.

NewsStand: What are some of the measures you must take to properly diagnose and treat patients for their orofacial pain?

Bender: One of my good friends and mentors Dr. Jeff Okeson calls orofacial pain a “thinking sport.” In dentistry, we spend a very short period of time taking a history and a longer time with the examination looking for a problem to fix. With orofacial pain it is necessary to spend more time taking a good history. In many cases, you will be able to make a very good differential diagnosis just by listening to patients before the examination. The words they use to describe their complaints — how it started, how it has progressed over time, what makes it worse, what makes it better — all provide valuable information in the diagnostic process.

The difficulty with pain is that it cannot be seen and is very subjective. After taking a good history, the job then becomes trying to reproduce the complaint. A very systematic approach to the exam process is necessary. You have to make sure that all areas of potential pain referral are not overlooked. It sounds time intensive, but once you practice it for a while, it proceeds quickly. Again, the greatest amount of time I spend with patients is taking a history and then consulting with them after the examination.

NewsStand: Quite often the patients you see who are dealing with head, neck and TMJ pain have been to multiple specialists and have spent thousands of dollars but to no avail. What mindset and training is needed to best address these patients’ needs in the private-practice world? In the dental school setting?

Bender: I tell patients all the time that my job is to help facilitate the body’s natural adaptive process and not make them feel worse. The temporomandibular joints have an amazing adaptive capacity, unlike any other joint in our body. In many cases, these issues will resolve by themselves over time. Treatments should always be as conservative as possible and based on evidence. This approach should be used both in the academic as well as the private-practice setting.

It is my hope that as we progress, we will have students and residents rotate through our clinic so that they can take away tools to help them diagnose and manage these patients in an evidence-based and ethical manner. As pain is subjective, it will affect each individual differently. Because we cannot necessarily see pain, it may be easy to dismiss some of our patients’ complaints or “try” different treatments in the absence of a definitive diagnosis.

Not only can we fill a huge need for the patients at the school and within the community, but we can also unify the teaching of temporomandibular disorders, facial pain and sleep disorders so that the students feel better prepared to diagnose and treat these issues when they graduate.