Case Study #007 Page 1 of 7

CASE STUDY

PRESENTED BY

WESLEY E. SHANKLAND,II, DDS, MS

PROSTHETIC PROBLEM MIMICKING A FACIAL PAIN DISORDER

History

A 59 year-old Caucasian male presented one day with the following chief complaints: “I can’t wear my denture.” According to this pleasant gentleman, when he was in his late 20s, several of his maxillary posterior teeth were removed because he was experiencing tooth pain, but he denied that he had any tooth problems. He saw several dentists and each time, he was examined, the doctor couldn’t find the problem, but yet, teeth were removed. Ultimately, all his maxillary teeth were removed and a complete denture was made. Unfortunately, he couldn’t wear his denture due to the same type of pain in his posterior maxilla. After several dentures were made by several different dentists, he resolved himself to wearing his denture only in public. Each time he wears his denture, his maxillary pain increases. In addition, there is pain radiation into the each ear and down into the throat bilaterally. He stated that his pain was minimal when he didn’t wear his denture, but each time he swallowed food, the ear and throat pain returned.

When the patient was examined, his complaints were as follows:

• Throat pain. He stated that he always had a low level of throat pain, but when he would swallow the pain would become intense. The pain was noticed on both sides of his throat. • Ear pain. The patient reported that, in addition to throat pain, he also experienced bilateral ear pain when he swallowed. The pain seemed deep inside each ear and would subside in about 20 minutes. Case Study #007 Page 2 of 7

• “I can’t wear my denture.” This gentleman stated that when he would insert his maxillary denture, all of his pain complaints immediately occurred and remained until the denture was removed.

Past Medical History

Aside from normal childhood diseases, this patient’s medical history appeared to be non- contributory to his complaints. He smoked approximately one pack of cigarettes a day for the past 40 years. He denied any known allergies to medications, denied mitral value prolapse or any other know systemic diseases or disorders.

Examination

Upon examination, the patient was alert, well-oriented, exhibited a normal gait, and was normally nourished. There was no apraxia; eyes were normal to confrontation; pupils were centered and reactive to light; cranial nerves II through XII were normal and intact. Her vital signs were as follows: Blood pressure: 130/90; Pulse: 76 beats per minute; temperature: 98.6 degrees.

Using a digital analog scale, the patient reported that his average, overall pain was 2.5 (based on a scale of 0 to 10), but when swallowing food or inserting his denture, the pain score was about 7.

Both temporomandibular joints were non-tender upon resting, digital palpation of the joint capsules, or lateral movements of the mandible. However, both joints were reported painful with wide opening and protrusive movements of the mandible.

Slight crepitation was detected, both with palpation and auscultation, in both joints, but neither joints were tender with any mandibular movement or with digital palpation of the joint capsules. Further, doppler sonography revealed crepitation in both joints with mandibular movements.

Maximum incisive opening was 48 mm, with a passive stretch opening of 54 mm. Left and right mandibular movements were approximately 10 mm each. Protrusive movement of the mandible was 10 mm.

Both temporalis muscles (the anterior bellies) and masseter muscles were slightly tender to palpation. Ranges of motion of the patient’s head and neck were reduced from the normal. In addition, he exhibited elevated shoulders and a forward head posture.

Oral examination demonstrated that all maxillary teeth were missing as well as teeth numbers 17-19 and 28 through 32. The remaining teeth were in fair repair. Oral cancer examination was normal. A tentative periodontal diagnosis was generalized chronic mild compound periodontitis. Case Study #007 Page 3 of 7

The patient’s oral mucosa appeared normal with no noticeable lesions or abnormalities. Insertion of his current denture demonstrated adequate retension of the prosthesis. When pressure was applied upwards on the palate of the denture, the patient complained of throat pain. Examination of the soft palate region revealed what seemed to be a very tender swelling bilaterally in the soft palate region. Pressure against either of these swellings produce pain radiation into the ipsilateral ear and lateral throat.

Radiographic examination was essentially normal. The stylohyoid complex appeared normal with no significant elongation or calcification of either styloid process.

Using a 30 gauge needle, approximately ¼ cc of 3% Mepivacaine was injected into the swollen area on the right side. During the injection, again, there was pain radiation into the ipsilateral ear and lateral throat. Within 5 minutes, the patient’s pain on the right side was totally gone. Insertion of the denture did not produce any pain on the right side. The left side was injected in a similar fashion.

Within 10 minutes of the first injection, all the patient’s pain complaints were gone. He inserted his denture and could wear it without any pain. He stated that this was the first time he’d been able to place a denture without pain for nearly 40 years.

Diagnosis

The tentative diagnosis was: bilateral bursitis of the tensor veli palatine bursae.

Treatment

A 1 cc mixture of 0.5% Marcaine and Sarapin was injected around both ptyerygoid hamuli (the swollen areas in the soft palate). The patient’s posterior palatal seal and denture extension were adjusted. He was placed on Vioxx 50 mg BID and told to stick to soft foods and return for re-evaluation in one week.

Re-evaluation

The patient was seen 7 days after the initial appointment. He reported that his palatal, ear and throat pain was nearly gone. He could now comfortably wear his denture at all times. The right side seemed a little more painful than the left. Upon examination, both hamular processes appeared tender to palpation. Both of these structures were once again injected with a 1 cc mixture of 0.5% Marcaine and Sarapin. He was told to continue taking the Vioxx, but only 50 mg daily for the next week.

Discussion Case Study #007 Page 4 of 7

As with all pain disorders, an accurate diagnosis must be determined or else the patient will (1) continue to suffer and (2) travel from office to office, spending money and not seeing any resolution of their pain complaints.

In this case, the key was his increase in pain when (1) he swallowed food and (2) he inserted his denture.

The sphenoid bone is a midline osseous structure lying anterior to the basilar portion of the occipital bone, shielded on either side by the temporal bones. The sphenoid has a central body, paired greater and lesser wings, and two pterygoid processes or plates descending from the junctions of the body and the greater wings.

The medial pterygoid processes or plates descend in an inferior and slightly lateral direction. The inferior end of the posterior border of the medial plate articulates with a slender, curved or hook-like process, namely the pterygoid hamulus (process or notch). Prior to 1993, anatomists thought that this process was simply an extension of the medial pterygoid plate. However, in 1993 and subsequently in 1996, evidence was given that these processes are actually bones themselves which, within the first month of a newborn’s life, articulate with the medial pterygoid plates. This articulation continues through life to provide movement so that the hamular process can act as a fulcrum for the tensor veli palatini muscle (Figures 1 and 2).

Figure 1: Pterygoid hamulus.

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Figure 2: Drawing of pterygoid hamulus. a: lateral pterygoid plate; b: medial pterygoid plate; c: pterygoid hamulus; d: suture between pterygoid hamulus and medial pterygoid plate.

The tensor veli palatini arises from the body of the sphenoid bone and the lateral surface of the Eustachian tube. It descends along the lateral surface of the superior pharyngeal constrictor to wind around the pterygoid hamulus and ultimately, to insert into its opposite fellow to form a large portion of the soft palate. A bursa encompassing the tendon of the tensor veli palatini was first reported as recently as 1996 (Figure 3).

The bursa grossly appears as a tubal structure through which the tendon of the tensor veli palatini passes (Figure 3). Like any other bursa in the body, it is susceptible to injury with the subsequent development of bursitis. This inflammation of the synovial lining of the bursa produces localized and referred pain.

Figure 3: Exposed hamular process and bursa (h). Case Study #007 Page 6 of 7

In the case of the bursa of the tensor veli palatini muscle, the following symptoms are often seen:

• Pain in the hamular notch region • Soft palate pain • Ipsilateral throat pain • Pain with swallowing • Ipsilateral ear pain • Swelling and erythema (at times) over the hamular process

Patients with this disorder often have a history of injury to the throat such as jabbing oneself with a tooth brush or being injured during intubation for a general anesthetic. At times, simply the exaggerated posterior extension of a maxillary complete denture can cause injury to one or both bursae. Also, some victims of sexual abuse, when forced to perform fellatio, injure these small processes.

If the history and diagnostic anesthetic injection confirms the diagnosis of hamular process bursitis:

• Adjustment of posterior extent of a denture • Prescribe a non-steroidal anti-inflammatory • Instruct the patient to adhere to a soft diet • Inject a mixture of a long-lasting anesthetic and Sarapin • Repeat if necessary

If conservative treatment fails, then consider surgical intervention. The surgical procedure consists of either incising the bursa, removal of the pterygoid hamulus, or both (Figure 4). Case Study #007 Page 7 of 7

Figure 4: Amputation of hamular process.

References

1. Shankland WE. Examination of the development and biomechanics of the hamular process of the sphenoid bone in humans. Master of Science Thesis. Columbus: The Ohio State University. 1993. 2. Shankland WE: Pterygoid hamulus bursitis: one cause of craniofacial pain. J Prosthet Dent 1996; 75:205-210. 3. Shankland WE: Bursitis of the hamular process. Part I: Anatomy and histological evidence. J Craniomand Pract 1996;14(3):186-189. 4. Shankland WE: Bursitis of the hamular process. Part II: Diagnosis, treatment and report of three case studies. J Craniomand Pract 1996;14(4):306-311.

Sarapin. High Chemical Corporation.