Getting To the Root Cause of Myogenic Tooth Pain

Carol Cote of North Jersey Physical Therapy Associates recently travelled to San Francisco to teach a full one-day program on Feb. 11, 2022 to the U2 Endodontic Study Group, with participants coming from throughout the western states, on the topic of myogenic tooth pain, and how physical therapists with specialty training can collaborate with endodontists to help identify it, and how physical therapists can then treat it.

Muscles can masquerade as tooth pain, which can be then be misdiagnosed resulting in persistent tooth pain, even after common dental procedures, such as a root canal, or even after a tooth extraction.  Close lock and painful problems of the TMJ, head and neck can develop that can limit or prevent an endodontist from performing a tooth saving root canal. Specially trained physical therapists who understand myogenic tooth pain are key members of a dentist’s/endodontist’s collaborative team.  Muscles and sinus issues are the key contribution to tooth pain that is not coming from the tooth.  As an expert in her field, Carol discussed the underlying physiology and how muscles can contribute to tooth pain, especially if it persists after a root canal.  There are three major muscle groups that can masquerade as tooth pain.  These muscle groups are:

  1. Muscles of the jaw
  2. Muscles of the throat (swallowing)
  3. Muscles of the neck

A thorough and extensive Physical Therapy Evaluation is critical to understanding the difference between the symptom of pain, the source of the pain, and the root cause of the pain.  Once the symptom, source, and root cause of the tooth pain are understood and identified, then proper treatment can begin consisting of key manual techniques and exercises unique to this area of the body, and different from traditional physical therapy methods. These typically provide the best strategy to address the root cause, and provide the patient with the means to achieve and maintain pain free function, without necessarily the need for pain medications or muscle relaxants, which typically address only the symptoms and not the root cause.


Fascia is highly innervated connective tissue, which spreads throughout your body in a 3-dimensional web from your head to your feet without interruption.  Trauma, posture, or inflammation can create a binding down of the fascia resulting in excessive pressure on nerves, muscles, blood vessels, osseous (bony) structures, and/or organs.

Standard tests such as x-rays, myelograms, CT scans, EMG, etc., do not assess the fascial systems.  It is the invisible system in a medical workup.  It can only be assessed during a hands-on clinical evaluation.  The viscoelastic quality of the fascial system causes it to resist a suddenly applied force.  The myofascial release approach consists of the gentle application of sustained pressure into the fascial restrictions.  This essential time element has to do with the viscous flow and the piezoelectric phenomenon.  A low order (gentle pressure) applied slowly will allow a viscoelastic medium (i.e. fascia) to elongate (stretch).

If you visualize a spider web, although delicate in appearance, the spider web is versatile, extremely strong, and vital not only because of its structural design, but to the survival of the spider itself.  When a fly gets trapped within a web, that fly not only affects the area of the web that binds it, but changes the tensile forces throughout the entire design, therefore, acting as a form of communication to the spider.  The same thing happens in our body with fascia.

What Is Fascia Made Of?

Fascia is made up of 3 main components: Collagen, Elastin, and Ground Substance.  Collagen is the silk thread of the spider web, except these threads are hollow.  Elastin are the fibers that are just like the elastic thread of the stretchy fabric found in our skinny jeans.  It provides ease of movement during the lengthening compression stretch of the fascial fibers.  Finally, the Ground Substance is the environment where the fascia resides.  Ground Substance when unrestricted is a liquid that flows inside and out of the hollow collagen threads preventing their hollow design from collapsing, as well as, lubricating the threads to assist in its movement of glide, slide, and pull.  Like Johnny Cash said, fascia is “everywhere man”.  When looking at fascia from a less cellular viewpoint it can be described as sheets, bands, or mesh.  It surrounds every nerve, blood vessel, ligament, tendon, muscle, organ and bone in one form or another, and in doing so provides for an interior network that not only provides structure to our body, but it helps absorb shock, and works as a transmission system signaling throughout the body.

Why Is Fascia Important?

When increased demands are placed on the fascia (repetitive stress, immobility, poor posture, injury, lack of hydration), the structure can be changed.  This change causes the ground substance to harden and that hardening causes fascial restriction.  The fascial restrictions then cause the body to prevent its structural integrity by limiting tissue restriction/motion normally available from the fascia, and stiffening it as a secondary method of strength by limiting the motion available from the fascia.  This is why fascial restriction can play a major role in pain and movement dysfunction.  Therefore, even after a bone or muscle heals after an injury, the fascia will not spontaneously release, which may have an effect on the surrounding structure.  Again, our fascial system is like a spider web, and a tug on one end can cause a change of structure on the other.

How We Treat Fascial Restriction At North Jersey Physical Therapy

Through our holistic approach to physical therapy, we understand the patient’s symptoms, but treat the root cause.  This is done by performing a movement examination, and pain neuroscience evaluation.  We then treat the patient utilizing various manual therapies including:

  1.  Myofascial Release
  2. Cupping
  3. Craniosacral
  4. Mobilization/Manipulation
  5. Dry Needling
  6. Functional and specific exercises to meet the patient’s needs.

What Is Active Release Technique (A.R.T.)

A.R.T. is a soft tissue method that focuses on relieving tissue tension via the removal of fibrosis / adhesions which can develop in tissue as a result of overload due to repetitive use.  These disorders may lead to muscular weakness, numbness, achiness, tingling and burning sensation.  A.R.T. has been reported to be both a diagnostic and treatment technique.

The design of A.R.T. is three fold:

  1. To restore free and unimpeded motion of all soft tissue.
  2. To release entrapped nerve vasculation and lymphatics.
  3. To re-establish optimal texture resistant function of soft tissue.

It involves the lengthening sliding motion of soft tissue (nerves, ligaments, muscles and fascia) conditions.

  1. Strains
  2. Hamstring Flexibility
  3. Carpal Tunnel Syndrome
  4. Muscle weakness secondary to scar tissue and fascial restriction inclusive of post-surgical scars.
  5. Myofascial pain
  6. Tendonitis
  7. Bursitis

Exercise is key:

A.R.T. is combined with key flexibility and strengthening exercises to stop faulty overuse and muscle memory.

Balance and Proprioception:

Balance and proprioception activity is introduced early.  Effective balance and proprioception exercises are designed to restore kinetic awareness of the patient.  These exercises form the basis for agility, strength and endurance for complete rehab.


Aerobic exercises are key to improving circulation to bring oxygen back to oxygen deprived tissue from strains and chronic soft tissue pain disorders such as myofascial pain.

A.R.T. is for all people with painful conditions, young, old, athletes, sedentary, sports injuries or de-conditioning, acute pain, chronic, persistent pain.

A.R.T. assesses biomechanical dysfunction that is often at the ROOT CAUSE of injuries.  People in pain do not move like people without pain.  Pain also changes how muscles work.

Lovelyn Ravago, DPT Joins NJPTA

Lovelyn Ravago DPT has joined NJPTA and brings with her a specialty in soft tissue treatment.  Lovelyn is certified as an ART (Active Release Technique) therapist.  Active Release Technique treats your body’s soft tissue by integrating manipulation, manual therapy, neuromuscular re-education, and movement.  In keeping with the treatment philosophy of NJPTA, she is a hands-on, one-on-one therapist who loves to help patients get out of pain and return to quality of life function.  With over 19 years of experience treating patients, she is committed to making a difference with her patients’ results.  She received her Doctorate in Physical Therapy (DPT) from the College of St. Scholastica, Duluth, Minnesota in 2019.

Lovelyn has a strong commitment to excellence and doing what it takes to address the ROOT CAUSE of a patient’s problem in order for the patient to regain pain free independence.  She employs a combination of techniques, including fascial mobilization, manual therapy, myofascial therapy, ART, joint mobilization, neuromuscular retraining and key exercises to help her patients return to full pain-free function in their daily lives.

Non-Odontalgic Tooth Pain (Pain Not Coming From The Tooth)

Carol N. Cote, PT, CCTT Presents at IAE (International Academy of Endodontics) Conference in Scottsdale, AZ on Non-Odontalgic (not coming from the tooth) Tooth Pain.

Carol was an invited guest speaker of the IAE on treating/resolving non-odontalgic tooth pain, which is tooth pain that does not come from the tooth. Many people present with tooth pain that does not come from the tooth. Endodontists are the experts in identifying and treating complicated tooth pain. They also save teeth that have deep fillings and cracks. They do complicated root canals on teeth that have atypical and convoluted roots. They use microscopes and 3-dimensional scans to fully assess the health of a tooth to ultimately save your teeth. But what happens when your tooth pain is not coming from the tooth, where the endodontic exam that is negative, but the tooth pain persists even after a root canal? For some patients the tooth pain persists even after the tooth has been excised! Obviously the wrong diagnosis and a mistake to do a root canal, or have the tooth pulled as it does not get to the “root cause” of that pain. Key muscles of the jaw and throat can refer pain to the teeth. Therefore, since there are no scans, MRI’s, ultrasounds to confirm that the pain exists or where it is coming from, the diagnosis is achieved by a process of exclusion through hands-on evaluation by a specialty trained physical therapist.

Endodontists, neurologists, orthopedics, periodontists, prosthodontists, or dentists evaluations can be negative in regards to identifying the pain. A highly skilled physical therapist in both soft tissue, palpation and specialized training in treatment of conditions of the jaw can assess, treat, and resolve this elusive pain. Carol presented several case studies showing the success of this method, as well as, the medical / dental evaluation and treatment protocols done by a physical therapist to solve this type of pain. The question and answer period following the presentation showed the appreciation of this endodontic group of the need for this type assessment capability to help patients resolve their tooth pain. The feedback from the endodontic group has been extremely positive. We have received emails from endodontists that were able to successfully assess the elusive and complicated myogenic tooth pain based on Carol’s presentation. One endodontist is even sending one of his patient’s from Utah to be evaluated by North Jersey Physical Therapy.