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A Case of Suspected Temporomandibular Disorder and Cracked Tooth

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A Case of Suspected Temporomandibular Disorder and Cracked Tooth A CASE OF SUSPECTED TEMPOROMANDIBULAR DISORDER AND CRACKED TOOTH Takashi Ishii, DDS, PhD1 A patient referred with a suspected temporomandibular disorder was exam- ined. Initial temporomandibular symptoms and pain subsided with normal dental treatment. However, over time, the patient began to develop trigeminal neuralgia-like symptoms. Typical symptoms appeared after about 1 year, and trigeminal neuralgia was eventually diagnosed. Surgery was performed at a neurosurgery department, leading to recovery. The initial symptoms in this case were pre-trigeminal neuralgia, the precursor to trigeminal neuralgia. INT J MICRODENT 2015;6:90–93 INTRODUCTION CASE REPORT In order to diagnose myofascial toothache, a non-odontogenic Patient: 60-year-old male toothache that appears as re- ferred myofascial pain of the mas- • Main complaint: left tempo- seter muscle,1 or toothache due romandibular joint noise, spon- to cracked tooth syndrome,2, 3 taneous pain of left mandibular which includes cracked teeth and molars is an odontogenic toothache, the • Medical history: The patient pathologies of these conditions had been attending an ortho- must be properly understood. It pedic surgery department for a is not possible to diagnose an un- cervical vertebral disc herniation known condition. for approximately 1 year. He had A case is reported in which both also received laser treatment the patient himself and the refer- for left temporomandibular joint ring doctor suspected temporo- noise, but there was no change. mandibular disorder. Since the He was prescribed neurotropin pain was not well characterized, and celecoxib by the orthopedic a mixed condition of myofascial surgery department. toothache and odontogenic tooth- • Family history: Nothing of note. ache was diagnosed. However, • History of present complaint: over time the patient began to The patient was examined by 1 Division of General Dentistry, The Nippon show typical symptoms of trigem- the referring doctor in February Dental University Hospital, Japan inal neuralgia, and the early-stage of XX for the main complaint of temporomandibular disorder-like noise in the left temporoman- Correspondence to: symptoms, toothache, and gingi- dibular joint and a stinging pain Takashi Ishii val symptoms were identied as in the left molar region when 2-3-16, Fujimi, Chiyoda-ku, Tokyo, Japan symptoms of pre-trigeminal neu- masticating. He was subse- 4, 5 E-mail: [email protected] ralgia. quently referred to this clinic for 90 THE INTERNATIONAL JOURNAL OF MICRODENTISTRY p90-93_Ishii.indd 90 15/10/19 11:40 Ishii Fig 1Preoperative ra- diograph of tooth 17 with a periapical radiolucency (5 x 5 mm). examination in April of that year. hours. myofascial toothache and chronic • Present condition: Fig 1 shows A cracked tooth2, 3 was suspect- periodontitis the orthopantomograph from ed as the patient complained of The patient was examined again the initial visit. The patient pain on mastication. Microscope in December of XX, complaining explained that the left molar has been a tremendous aid in of pain in the left maxillary second region had stinging pain on the diagnosis and treatment of molar. Caries were found in the mastication, there was pain in cracked teeth. Examination of the distal side of the diseased tooth, the mandibular left molar region teeth with the microscope may and a 5.0-mm pocket was present when his body became warm, help detect cracks. But close ex- all around the tooth (Fig 1), but and the pain did not occur just amination by microscopy revealed patient has no spontaneous pain, with opening and closing the no abnormality such as a fracture induced pain, or pus discharge. mouth. A structured interview or crack in this case. The pain Since the main complaint was relating to the pain (Table 1) was could not be recreated by having shooting pain, it was concluded subsequently performed. the patient bite hard on a wooden that the cause was not inamma- chopstick. tory pain such as chronic periodon- The results of a structured Referred pain did not appear in titis. A structured interview was interview regarding the pa- the left mandibular molar region again performed, and trigeminal tient’s symptoms are present- with palpitation of the left masse- neuralgia was suspected because ed in Table 1 ter muscle, but since the patient the patient complained of obvious complained of pain, he was given shooting pains when washing his There was no laterality in skin, in- guidance in stretching the mas- face or masticating. Examination traoral sensation, allodynia of the seter muscle. The mandibular left at the neurosurgery department gums on the left side, history of rst and second molars were ab- was recommended. However, shingles, ischemic heart disease, sent, and the wisdom tooth was because the patient was still sus- or headaches, and no pain of the mesially inclined (Fig 1), and the pected of having temporomandib- left masseter muscle, such as patient complained of pain when ular disorder even at that time, he pressure pain on muscular palpita- food accumulated in the wisdom was examined by the TMD center tion. Primary disease was there- tooth mesial region. He was there- of this hospital. Although some fore excluded in accordance with fore given guidance on interdental pressure pain was found in the left the criteria for orofacial pain.6 In brush use, and as the pain abated, masseter muscle, TMD was ruled addition, when the patient took subsequent progress was ob- out. NSAIDs approximately 3 weeks served without further treatment. The patient was examined at the prior, the pain stopped for about 2 At this point, the diagnosis was neurology department of Hospital Volume 6 • Number 2 • 2015 91 p90-93_Ishii.indd 91 15/10/19 11:40 Ishii TABLE 1Pain-related structured interview results. Topic Question Response Left buccal region and 1. Site Where does it hurt? left mandibular molar region Was there anything that 2. Circumstances of appearance No particular reason triggered the pain? How long has it been since It has felt like this 3. Progress the pain started? for about a year 4. Type of pain What type of pain is it? Stinging pain 5. Degree of pain How intense is the pain? VAS 10–20/100 Several times a day, some days 6. Frequency How often does the pain occur? there is none at all How long does a single episode 7. Duration Momentary of pain last? Does the pain have any change 8. Temporal features Nothing in particular in features with time? Are there any factors that bring Sometimes occurs 9. Inducing, aggravating factors the pain on or make it worse? when eating something Is there anything that 10. Alleviating factors The pain eases with painkillers lessens the pain? Are there any other symptoms that 11. Associated symptoms Nothing in particular occur when it hurts? Is there anything that you always do 12. Behavior during pain Nothing in particular when you feel pain? A in March of XX+1, but trigeminal rosurgery department of Hospital DISCUSSION neuralgia was apparently not diag- B revealed that the left trigeminal nosed because skin palpation did nerve was under pressure from The denitive diagnosis was de- not induce pain. However, trigemi- an artery, and carbamazepine was layed in this case because the pa- nal neuralgia or glossopharyngeal prescribed. However, the patient tient himself strongly suspected neuralgia was suspected as the could not take carbamazepine due temporomandibular disorder, and patient complained of shooting to the side effects, and the pain because the typical symptoms pains when masticating and swal- grew more intense, thus surgery of trigeminal neuralgia were not lowing, with pain at almost every was performed at an early stage. evident. There is a precursor to meal and from just swallowing Suboccipital craniotomy and mi- trigeminal neuralgia, called pre- saliva. The patient was therefore crovascular decompression were trigeminal neuralgia, and patients referred to the neurosurgery de- carried out, and the pain in the become aware of this because of partment of Hospital B for close left side of the face disappeared toothache and pain due to maxil- examination and treatment. completely immediately following lary sinusitis.4 In addition, slight to MRI and CISS (three-dimen- surgery. moderate dull, pulsating, or burn- sional MRI) imaging at the neu- ing pain, aching gums, and tooth- 92 THE INTERNATIONAL JOURNAL OF MICRODENTISTRY p90-93_Ishii.indd 92 15/10/19 11:40 Ishii ache are sometimes found.5 toothaches.9 However, since this aminations for orofacial pain. If the Cases of trigeminal neuralgia condition is not yet generally cause is clearly a tooth, exclusion or pre-trigeminal neuralgia such known among dentists, they are diagnostic dental treatment will as the present case are easily often unable to diagnose it and be needed to determine whether mistaken for toothache, and the provide treatment. the pain is odontogenic or non-od- diagnosis becomes even more With the present case, pre- ontogenic. However, if an organic difcult when trigeminal neuralgia trigeminal neuralgia was not cause cannot be found and the and toothache are present togeth- considered as the patient and symptoms seem atypical, non- er.7 Many patients with trigeminal the referring doctor suspected odontogenic toothache should be neuralgia have dental examina- temporomandibular disorder, and suspected. tions because they become aware the author suspected myofascial The cause of the pain in the pre- of toothache, and thus end up toothache and odontogenic pain. sent case was trigeminal neural- having unnecessary dental treat- For this reason, it took approxi- gia, and since other diseases that ment.8 mately a year for a denitive diag- cause non-odontogenic toothache Pain felt in the teeth despite no nosis and to subsequently provide also exist, it would be desirable for cause in the tooth or the periodon- the present report, for this the au- endodontists to be familiar with tal tissues is known as non-od- thor regrets this delay.
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