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Wesley E. Shankland,Ii, Dds, Ms American Academy of Craniofacial Pain: Case Study Page Page 1 of 10 CURRENT CASE STUDY PRESENTED BY WESLEY E. SHANKLAND,II, DDS, MS, History A 42 year-old female presents with the following chief complaint: “My jaws are killing me and I have headaches every day.” According to the patient, 9 months earlier, she was stopped at a traffic light, driving a Toyota Celica. She heard the sound of tires squealing and looked up to the right into her rearview mirror just in time to see a Dodge Caravan about to hit her car in the rear end. She braced herself and at the moment of impact, her c was propelled forward, forcing her body, in a relative fashion, posteriorly, towards the impact. The cervi portion of her neck struck the head rest, and then her body was thrown forward, finally stopped by the shoulder harness. She didn’t lose consciousness, although she was dazed for a short time. After getting out of the car, she h immediate headache, neck and low back pain. She was transported to the nearest hospital where she was examined and radiographs were taken of her cervical spine and lumbar region. The radiologist felt there w no abnormalities. The emergency room doctor couldn’t find any evidence of direct head trauma. Her diagnoses were: Cervical strain. She was given a prescription for Ibuprofen (600 mg every 6 hours for 10 days) and Flexeril (10 mg tid for 10 days) and told to see her family physician or return to the emergency room if she didn’t improve in a few days. The patient didn’t improve, but became worse. She developed constant headaches, bilateral ear and mandibular pain, and neck stiffness. She saw her family doctor who referred her for physical therapy and changed her medications to Vioxx and Soma. The physical therapy made her symptoms worse. The patient saw several doctors (two neurologists and an ENT physician), but her symptoms did not imp Finally, she saw a chiropractor and her neck complaints improved, but were still present. In addition to h daily headaches and mandibular pain, she developed a reciprocal click in her right temporomandibular (T American Academy of Craniofacial Pain: Case Study Page Page 2 of 10 joint, which was first noticed by the chiropractor. This doctor referred the patient to a craniofacial pain specialist. When the patient was examined by the craniofacial pain doctor, in addition to her chief complaint (see ab she had the following other complaints: 1.Constant daily headaches. She always has a headache, even when waking. Her headaches are least pain when waking, but seem to get worse as the day goes on. Chewing, talking, singing all make the headache worse. 2.Jaw pain. The patient stated that both sides of her jaws feel “bruised.” Wide opening of her jaws makes pain worse, causing pain radiation from the jaws into the TMJs, ears and temporal regions bilaterally. 3.Facial pain. In addition to the headaches and jaw pain, the patient stated that she had frequent mid-facia pain, which seemed to be worse when the jaw pain was severe. 4.Clicking in her right temporomandibular joint with any jaw movement. The patient reported that every she’d move her jaw, even when swallowing, her right joint would click. There was no locking, just clicki At times, the clicking would be painful and at other times, non-painful. 5.Drowsiness. The patient reported that she’s been drowsy “all the time” since her accident. She was slee well and maybe her muscle relaxants (first Flexeril and then, Soma) contributed to her drowsiness. Past Medical History This 42 year-old Caucasian married female denies having any of these symptoms prior to the motor vehi accident, aside from the normal tension headaches, “. .which everyone gets once in a while.” She had undergone three general anesthetics prior to the accident (age 16: removal of third molars; age 24: D&C; age 39: cholecystectomy). She had undergone orthodontic therapy (4 bicuspid extractions) in her teenaged years. She 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 nouris There was no apraxia; eyes were normal to confrontation; pupils were centered and reactive to light; cran nerves II through XII were normal and intact. Her vital signs were as follows: Blood pressure: 120/72; Pu 70 beats per minute; temperature: 98.4 degrees. Using a digital analog scale, the patient reported that her average, overall pain was 5.5. Both temporomandibular joints were non-tender upon resting, digital palpation of the joint capsules, or la movements of the mandible. However, both joints were reported painful with wide opening and protrusiv movements of the mandible. Reciprocal clicking was detected, both with palpation and auscultation. Further, doppler sonography reve no crepitation or rhronci with mandibular movements. American Academy of Craniofacial Pain: Case Study Page Page 3 of 10 Maximum incisive opening, without pain, was 35 mm, with a passive stretch opening of 44 mm, produci bilateral joint, ear and mandibular pain. Left and right mandibular movements were approximately 8 mm An opening click was detected in the right joint at 14 mm of opening and a closing click was detected at mm prior to maximum intercuspation in the right joint. Left, right and protrusive movements of the mandibular produced no joint noises. The following structures were tender to palpation: 1. Both temporalis muscles (anterior bellies) 2. The right occipitalis 3. Both trapezius muscles 4. Both sternocleidomastoid muscles 5. Both masseter muscles 6. Both stylomandibular ligaments 7. Both temporal tendons, the right worse than the left 8. The right zygomandibularis muscle Ranges of motion of the patient’s head and neck were reduced from the normal. In addition, she exhibite elevated shoulders and a forward head posture. Oral examination demonstrated that this patient exhibited a Class II skeletal relationship, but a Class I de malocclusion. Anterior guidance and bilateral cuspid disclusion were present. There were minor evident faucets and mild gingival recession generally. Teeth numbers 1, 5, 12, 16, 17, 21, 28 and 32 were missin remainder of her teeth were in good repair. A tentative periodontal diagnosis was generalized, chronic, compound periodontitis. Oral cancer examination was normal. A panoramic radiograph was taken and was essentially normal, with nor fractures or pathological lesions visible. There was slight calcification of the right stylohyoid ligament. Transcranial radiographs were taken which demonstrated normal bony architecture in both joints. Howev the right mandibular condyle was posteriorly and superiorly displaced within its mandibular fossa. Condy translation was normal within both joints. Vapocoolant spray applied to both temporalis muscles and both masseter muscles provided only mild rel Anesthetic blockade of both temporal tendons provided approximately 50% relief of her pain symptoms. Diagnosis The tentative diagnoses for this patient were: 1. Myofascial pain dysfunction American Academy of Craniofacial Pain: Case Study Page Page 4 of 10 2. Bilateral temporal tendonitis 3. Anteriomedial dislocation, with reduction, of the right temporomandibular joint Treatment The patient’s medications were changed to the following: 1. Skelaxin 1-2 q6h prn muscle pain 2. Vioxx 25 mg, #40; 1 bid for 5 days and then 1qd 3. Nortriptyline 10 mg, 1 hs In addition, the patient was instructed to increase her water consumption and take glucosamine (approxim 1,500 mg) and chondroitin sulfate (approximately 1,000 mg) twice a day with 500 to 1,000 mg of vitami each time. The patient was also placed on a soft diet, limited mandibular movements, and application of ice followe moist heat over both anterior temporal regions after eating or in times of increased pain. Both temporal tendons were injected with a 2 cc mixture of 0.5% Marcaine and Sarapin. Due to the evident wear faucets and generalized gingival recession, a nighttime NTI appliance was fabric and placed. The patient was instructed to wear the NTI appliance whenever she slept, even when taking a She was told to continue seeing her chiropractor and reappointed in two weeks. Re-evaluation When seen again in two weeks, the patient was doing better. Her digital analog scale had decreased from to 4.2. She reported that she was sleeping better and she was not as tired as when she was first seen. She had daily headaches, but they were markedly improved. Her NTI needed minor adjustment. Both temporalis (anterior bellies), the right zygomandibularis muscle, the stylomandibular ligaments, and temporal tendons were tender to palpation. Maximum incisive opening had improved from 35 mm to 42 and lateral mandibular movements had improved to 10 mm each. However, border movements (or, extre mandibular movements) still produced bilateral mandibular pain. Reciprocal clicking was still present in the right temporomandibular joint. Both temporal tendons were again injected with 1.5 cc of 3% Mepivacaine. The patient reported that approximately 50 to 60% of her head pain was relieved, but her mandibular and TMJ pain persisted. The zygomandibularis tendon was then injected with 1 cc of 3% Mepivacaine, resulting in an additional 10 to reduction of pain. Using a ball burnisher, the stylomandibular ligament insertions were located and then compressed, produ pain radiation into the ipsilateral mandible, TMJ, ear, mid-face, and anterior temporal region. Anesthetic blockade of both stylomandibular ligaments, using 1 cc each of 3% Mepivacaine, relieved all remaining American Academy of Craniofacial Pain: Case Study Page Page 5 of 10 Diagnosis: (1) bilateral Ernest syndrome; (2) bilateral temporal tendonitis; (3) right zygomandibularis tendonitis; and (4) anteriomedial dislocation, with reduction, of the right temporomandibular joint.
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