{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T12:10:17Z","timestamp":1789992617950,"version":"4.0.1"},"reference-count":35,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,9,19]],"date-time":"2026-09-19T00:00:00Z","timestamp":1789776000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Non-odontogenic toothache often persists without an identifiable dental cause and may lead to unnecessary pulpectomy or tooth extraction. It may also result in long-term combined use of psychotropic medications, forming a recurrent clinical pattern. Ultrasound-guided fascia hydrorelease (US-FHR) targeting fascia-derived pathology has been applied to non-odontogenic toothache; however, treatment regions have not been systematically described. This article presents a proposed eleven-point US-FHR protocol for non-odontogenic toothache and related orofacial pain. Materials and Methods: This is an experience-based clinical protocol; it is not an efficacy study and does not include a new prospective study on human participants. The protocol was organized on the basis of long-term clinical experience at Kimura Pain Clinic and a focused literature search. Results: The protocol comprises 11 POINTs distributed across six anatomical regions: (1) three POINTs in the masticatory muscle region, (2) three POINTs in the medial pterygoid and capsular region, (3) one POINT in the parotid region, (4) two POINTs in the cervical region, (5) one POINT in the facial-artery region, and (6) one POINT in the upper posterior cervical region. For each POINT, the anatomical rationale, referred-pain pattern, procedural concept, and safety considerations are described. Conclusions: The proposed eleven-point protocol represents an expanded and structured development of the earlier four-region approach. Prospective, ideally controlled, studies are needed to evaluate its clinical effectiveness.<\/jats:p>","DOI":"10.3390\/medicina62091808","type":"journal-article","created":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T10:25:43Z","timestamp":1789986343000},"page":"1808","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["An Eleven-Point Ultrasound-Guided Fascia Hydrorelease Protocol for Non-Odontogenic Toothache and Orofacial Pain: A Clinical Protocol"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-8959-5748","authenticated-orcid":false,"given":"Hiroaki","family":"Kimura","sequence":"first","affiliation":[{"name":"Kimura Pain Clinic (Medical Corporation Fascia Research Association), Maebashi 371-0013, Gunma, Japan"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"},{"role":"project-administration","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Tadashi","family":"Kobayashi","sequence":"additional","affiliation":[{"name":"Development of Community Healthcare, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Aomori, Japan"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"methodology","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-5753-7671","authenticated-orcid":false,"given":"Ryoya","family":"Asaka","sequence":"additional","affiliation":[{"name":"Kimura Pain Clinic (Medical Corporation Fascia Research Association), Maebashi 371-0013, Gunma, Japan"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Hideaki","family":"Obata","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, Kawagoe 350-8550, Saitama, Japan"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"methodology","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,19]]},"reference":[{"key":"ref_1","unstructured":"Japanese Society of Orofacial Pain (2019). Clinical Practice Guideline for Non-Odontogenic Toothache (Revised Edition 2019), Japanese Society of Orofacial Pain. Available online: https:\/\/jorofacialpain.sakura.ne.jp."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1016\/j.jbmt.2015.11.012","article-title":"A fascia and the fascial system","volume":"20","author":"Stecco","year":"2016","journal-title":"J. Bodyw. Mov. Ther."},{"key":"ref_3","first-page":"138","article-title":"Ultrasound-guided fascia hydrorelease for pain in the dental region","volume":"45","author":"Kimura","year":"2020","journal-title":"Dent. Diam."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1018","DOI":"10.1093\/pm\/pnz170","article-title":"Expansion of 1 mL of Solution by Ultrasound-Guided Injection Between the Trapezius and Rhomboid Muscles: A Cadaver Study","volume":"21","author":"Kimura","year":"2020","journal-title":"Pain Med."},{"key":"ref_5","first-page":"e78867","article-title":"Fascial Ultrasound-Guided Injection: Where Do We Really Inject?","volume":"17","author":"Shiwaku","year":"2025","journal-title":"Cureus"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"896","DOI":"10.1002\/ca.23408","article-title":"Dermatome and fasciatome","volume":"32","author":"Stecco","year":"2019","journal-title":"Clin. Anat."},{"key":"ref_7","unstructured":"Donnelly, J.M., Fern\u00e1ndez-de-las-Pe\u00f1as, C., Finnegan, M., and Freeman, J.L. (2018). Travell, Simons & Simons\u2019 Myofascial Pain and Dysfunction: The Trigger Point Manual, Wolters Kluwer\/Lippincott Williams & Wilkins. [3rd ed.]."},{"key":"ref_8","unstructured":"Japanese Non-Surgical Orthopedics Society (2026, June 09). Proposal of Fascial Pain Syndrome (FPS). Available online: https:\/\/www.jnos.or.jp\/for_medical#2-11_Fascial_pain_syndromeFPS."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1307","DOI":"10.14219\/jada.archive.2000.0384","article-title":"Referred craniofacial pain patterns in patients with temporomandibular disorder","volume":"131","author":"Wright","year":"2000","journal-title":"J. Am. Dent. Assoc."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1295","DOI":"10.1016\/j.jpain.2010.03.005","article-title":"Referred pain from muscle trigger points in the masticatory and neck-shoulder musculature in women with temporomandibular disorders","volume":"11","author":"Svensson","year":"2010","journal-title":"J. Pain"},{"key":"ref_11","first-page":"117","article-title":"Craniofacial muscle pain: Review of mechanisms and clinical manifestations","volume":"15","author":"Svensson","year":"2001","journal-title":"J. Orofac. Pain"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Kimura, H., Kobayashi, T., and Obata, H. (2026). A Conceptual Fascial Memory Reset Hypothesis: Mechanobiological Insights into Stacking Fascia as an Ultrasound-Visible Structural Phenotype and the Potential Role of Fascial Hydrorelease. Int. J. Mol. Sci., 27.","DOI":"10.20944\/preprints202603.1500.v1"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"(2020). International Classification of Orofacial Pain, 1st edition (ICOP). Cephalalgia, 40, 129\u2013221.","DOI":"10.1177\/0333102419893823"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"6","DOI":"10.11607\/jop.1151","article-title":"Diagnostic Criteria for Temporomandibular Disorders (DC\/TMD) for Clinical and Research Applications: Recommendations of the International RDC\/TMD Consortium Network and Orofacial Pain Special Interest Group","volume":"28","author":"Schiffman","year":"2014","journal-title":"J. Oral Facial Pain Headache"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"843","DOI":"10.1111\/joor.12208","article-title":"Systematic review and recommendations for nonodontogenic toothache","volume":"41","author":"Yatani","year":"2014","journal-title":"J. Oral Rehabil."},{"key":"ref_16","first-page":"134","article-title":"Transient neuronal injury followed by intravascular injection during an ultrasound guided stellate ganglion block","volume":"2","author":"Shankar","year":"2013","journal-title":"Anesth. Pain Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e18168","DOI":"10.1097\/MD.0000000000018168","article-title":"Tonic\u2013clonic seizure during the ultrasound-guided stellate ganglion block because of an injection into an unrecognized variant vertebral artery: A case report","volume":"98","author":"Lu","year":"2019","journal-title":"Medicine"},{"key":"ref_18","first-page":"56","article-title":"Myofascial pain with referral from the anterior digastric muscle mimicking a toothache in the mandibular anterior teeth: A case report","volume":"51","author":"Kalladka","year":"2020","journal-title":"Quintessence Int."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"737","DOI":"10.1002\/jor.24251","article-title":"Increased pain and sensory hyperinnervation of the ligamentum flavum in patients with lumbar spinal stenosis","volume":"37","author":"Benditz","year":"2019","journal-title":"J. Orthop. Res."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"780","DOI":"10.1002\/ca.24220","article-title":"Ultrasonographic assessment of the lateral pterygoid muscle for BoNT-A injection","volume":"38","author":"Bae","year":"2025","journal-title":"Clin. Anat."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"41","DOI":"10.5125\/jkaoms.2024.50.1.41","article-title":"Ultrasound-guided intraoral botulinum toxin injection into the lateral pterygoid muscle for chronic temporomandibular joint dislocation","volume":"50","author":"Lee","year":"2024","journal-title":"J. Korean Assoc. Oral Maxillofac. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1007\/s11916-014-0424-5","article-title":"Ultrasound-guided stellate ganglion block: Safety and efficacy","volume":"18","author":"Narouze","year":"2014","journal-title":"Curr. Pain Headache Rep."},{"key":"ref_23","first-page":"e25484","article-title":"The Posterior Atlantooccipital Membrane: The Anchor for the Myodural Bridge and Meningovertebral Structures","volume":"14","author":"Scali","year":"2022","journal-title":"Cureus"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Hiroki, T., Kimura, H., Kobayashi, T., Horigome, H., Suda, M., Fukui, S., Suto, T., and Obata, H. (2026). The Analgesic Effect of Ultrasound-Guided Fascia Hydrorelease around the Artery for Myofascial Neck Pain: A Prospective Single-Arm Interventional Study. PLoS ONE, 21.","DOI":"10.64898\/2026.07.01.26356632"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"262","DOI":"10.1097\/00007632-199004000-00002","article-title":"Ultrastructure of the human interspinous ligament and ligamentum flavum. A preliminary study","volume":"15","author":"Yahia","year":"1990","journal-title":"Spine"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1811","DOI":"10.1111\/os.12802","article-title":"Histologic Observation and Significance of Sympathetic Nerve Fiber Distribution on Human Cervical Ligamentum Flavum","volume":"12","author":"Wu","year":"2020","journal-title":"Orthop. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1007\/s00276-013-1185-2","article-title":"Ultrasonography in myofascial neck pain: Randomized clinical trial for diagnosis and follow-up","volume":"36","author":"Stecco","year":"2014","journal-title":"Surg. Radiol. Anat."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"891","DOI":"10.1007\/s00276-011-0876-9","article-title":"Hyaluronan within fascia in the etiology of myofascial pain","volume":"33","author":"Stecco","year":"2011","journal-title":"Surg. Radiol. Anat."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"552","DOI":"10.1111\/joa.12866","article-title":"Quantification of hyaluronan in human fasciae: Variations with function and anatomical site","volume":"233","author":"Fede","year":"2018","journal-title":"J. Anat."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Pirri, C., Pirri, N., Macchi, V., Porzionato, A., De Caro, R., \u00d6z\u00e7akar, L., and Stecco, C. (2025). Ultrasonography of the Fasciae and Common Pathologies: The Game Changer. Diagnostics, 15.","DOI":"10.3390\/diagnostics15091180"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Pirri, C., Fede, C., Fan, C., Guidolin, D., Macchi, V., De Caro, R., and Stecco, C. (2021). Ultrasound Imaging of Head\/Neck Muscles and Their Fasciae: An Observational Study. Front. Rehabil. Sci., 2.","DOI":"10.3389\/fresc.2021.743553"},{"key":"ref_32","first-page":"40","article-title":"Effects of Interfascial Injection of Bicarbonated Ringer\u2019s Solution, Physiological Saline and Local Anesthetic Under Ultrasonography for Myofascial Pain Syndrome\u2014Two Prospective, Randomized, Double-Blinded Trials","volume":"125","author":"Kobayashi","year":"2016","journal-title":"J. Juzen Med. Soc."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"115","DOI":"10.11152\/mu-1362","article-title":"Ultrasound Guided Injection for Medial and Lateral Pterygoid Muscles: A Novel Treatment for Orofacial Pain","volume":"20","author":"Chen","year":"2018","journal-title":"Med. Ultrason."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"11","DOI":"10.4103\/jpgm.jpgm_797_21","article-title":"Ultrasound-guided dry needling of masticatory muscles in trigeminal neuralgia\u2014A case series of 35 patients","volume":"69","author":"Vas","year":"2023","journal-title":"J. Postgrad. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"379","DOI":"10.1016\/j.pmrj.2009.01.014","article-title":"C1-2 Steroid Injection for Crowned Dens Syndrome","volume":"1","author":"Frey","year":"2009","journal-title":"PM&R"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/9\/1808\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T11:28:27Z","timestamp":1789990107000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/9\/1808"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,19]]},"references-count":35,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["medicina62091808"],"URL":"https:\/\/doi.org\/10.3390\/medicina62091808","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,19]]}}}