March 3, 2020
by Sherif M. Elsaraj, DMD, MS; Mervyn Gornitsky, DDS, FRCD; Ana Miriam Velly, DDS, MS, PhD
Orofacial pain can pose a diagnostic challenge to a practitioner who is examining a patient with history of facial pain. Known and unknown aetiologies can contribute to pain symptoms. There are often problems arising from the subjective nature of pain due to the presence of multi-factorial causes. This may lead to differential diagnoses including psychogenic, neurological, vascular disorders and referred pain patterns from other areas of the body. This case report presents a case of a patient with a history of orofacial pain over three years with multiple doctor visits and only limited success. A thorough head and neck evaluation revealed right myofascial pain due to a worn set of full upper and lower dentures. Keeping the set of dentures at our office for a week produced complete remission of the pain.
The diagnosis of orofacial pain remains to be a challenge due to the subjective nature of pain perception which can be modulated by a combination of psychosocial and pathophysiological factors,1-2 the objective criteria of pain remains not well understood. Chronic pain can alter the patient effect to such extent that the practitioner is tempted to label the condition as “psychogenic”.3 To date, numerous research is done to define and classify facial pain; however, more work is still required to filter out contradictory and controversial findings. Due to the current incomplete understanding of the etiology, classification and management of chronic pain, these topics are frequently underemphasized in the medical and dental education curriculum.4
An 87-year-old indigenous female referred by otolaryngology to the dental clinic at the Jewish General Hospital with chief complaints of jaw pain, inability to speak, changing voice pattern and pain on eating and palpation of the right side of face. She reported a three-year history of continuous dull aching pain. Previous evaluations by a neurologist and an otorhinolaryngologist did not find a definitive etiology for the pain. The right sided pain has prevented her from eating and chewing. She also complained that her voice changed and was unable to speak properly within the last six-months. She is taking medication for thyroid disease, cholesterol reducing statin, and a proton pump inhibitor for gastrointestinal reflux disease due to the inability to chew food appropriately. No relief was provided by these medications.
A head and neck examination revealed an edentulous female wearing full upper and lower dentures (Fig. 1). She wore the dentures daily including at night. Full mouth examination revealed no pathology other than a wound in the upper right flange involving the upper denture. The patient has been edentulous for continuous 15 years and the dentures are not stable. She wore the dentures daily including during sleep. The buccal right flange of the upper denture was impinging on the upper right maxillary tuberosity area. The right lateral pterygoid and right masseter muscles were tender to palpation. No deviation, no clicking, popping or crepitus was noted in either temporomandibular joint. Examination of the dentures revealed excessive wear on the artificial teeth and poor intercuspation along with prognathic mandibular closure. Tooth contact in the mandibular rest position was evident. Panoramic radiograph revealed that the mandible and maxilla are both atrophic (Fig. 2).
Since all pharmacological therapy has been ineffective in alleviating the pain and several deficiencies were noted with the existing dentures. It was felt that at this point the only possible cause for the pain is indeed the denture. Therefore, her old dentures were taken away from the patient with permission and she was instructed to eat soft diet for a week. The removal of the dentures completely abolished the pain effect. She was then referred to her dentist for fabrication of a new set of teeth. The patient was happy and relieved to have witnessed that the denture was the cause of her agony.
The evaluation of this patient suggested a potential myofascial etiology for her facial pain. Most notably, oral parafunctional activity (bruxism) was suggested by the extreme wear of all artificial teeth. Parafunctional activity, in turn, result in increased loading of the masticatory muscles which can cause myofascial pain. Although the reasons for parafunction are unclear, evidence suggests no direct relationship exists between occlusion and developing myofascial pain.5-12 Orofacial pain can have local causes involving teeth, mouth, face, or head-related pain due to trauma, tumors or cysts, etc. However, psychogenic, neurological, vascular disorders and referred pain patterns from other origins of the body may need to be ruled out.5 In this case, poor denture design appeared to be contributing to the patient’s parafunctional habit. It is possible that malposition of the mandible, as dictated by the position of the denture, created strain on the muscles of mastication, which ultimately resulted in pain. Continuous wearing of the dentures without the usually recommended removal during sleep may have exacerbated the patient’s problem.
The dental practitioner is primary diagnostician for pain of local causes in the oral maxillofacial complex. The cause of most orofacial pain is established mainly from history and clinical examination findings. Data collection and case history is the most important means of diagnosing orofacial pain. Important key points when collecting pain data are: (1) pain classification: acute versus chronic, (2) pain pattern: localized, generalized, or referred, and (3) pain character: sharp, dull, aching, throbbing, shooting pain. Furthermore, having a visual analogue scale is very helpful for patients to quantify their pain from 0-10. These are important descriptors in monitoring patient’s progress to treatment.
To date, one case report13 of a 50-year-old white male reported a 12-year history of intermittent episodes of severe left auricular pain. This pain was thought to be neuropathic in origin by assessments from his neurologist; however, the author illustrated that orofacial pain thought to be neuropathic in origin may in fact be due to other etiologic factors.13 Although gum irritation due to an ill-fitting denture may cause pain; however, other symptoms may range from popping or pain in the jaws, headaches, or neck pain which patients may not be prepared for. All these symptoms can be caused by temporomandibular disorders (TMD). TMD pain is a very common problem characterized by pain, clicking and jaw locking or restricted range of motion. It is the second most common musculoskeletal pain condition after chronic back pain, affecting about 5-12% of the general population.14 A large proportion of these patients often report significant disability, psychological distress, and negative quality of life.15-16 These potentially debilitating health outcomes are more pronounced in patients with headaches, migraine, fibromyalgia and widespread pain involving the neck, back and extremities. These patients are more complex to treat and often show signs of delayed recovery and persistent chronic pain.17-21 TMD Diagnosis is based on clinical examination. TMD pain is usually dull, poorly localized, may radiate widely and is usually intensified by movement of the mandible and maybe associated with trismus because of spasm in the masticatory muscles.5 In this case, the etiology of a three-year history continuous dull aching severe pain, was a combination of gum irritation due to an ill-fitting denture, and myofascial TMD-related pain.
A diary can be an essential record of whether the pain occurs at specific times, with hot or cold foods and its duration and severity. It may be necessary to ask leading questions such as if biting, posture, analgesics, alcohol, smoking or stress modulate the pain. Additional investigations using CT or MRT imaging maybe indicated.5 This is crucial not to miss a brain tumour or degenerative temporomandibular joint that maybe the cause of the patient’s pain and prevent mislabeling with psychogenic pain.5 A patient with mild TMD pain and no comorbid conditions may be treated with self-care strategies such as relaxation, massage, hot/warm face-cloth or cold packs, stretching, exercise or a combination of these to encourage healing. A patient with TMD pain coupled with fibromyalgia, persistent clenching, anxiety, and depression should be treated in a multidisciplinary orofacial pain clinic setting in which a team of clinicians addresses different aspects of the patient’s symptoms. Multidisciplinary teams that include a dentist, sleep physician, physiotherapist and a psychologist can address all contributing factors, including comorbid conditions, in a supportive environment.
Limited approaches that do not address the full scope of a patient’s condition are likely to fail and complicate future therapy.
Reassurance and conservative measures are vital in management. A combination of rest, jaw exercises, soft diet, sleep hygiene, low stress life-style, appliance therapy and analgesics are some management modalities. A thorough comprehensive clinical examination where time is dedicated to listen and examine patients is crucial in the diagnosis of the problem in hand. Identifying comorbid conditions that range from muscle tension, depression, widespread pain, sleep apnea and fibromyalgia may impact treatment prognosis. This area of research needs to be further investigated. Dentists should identify patients with comorbid conditions and seek help from specialists’ referrals. This will aid in ensuring the highest standard of care to patient management.
Oral Health welcomes this original article.
Declaration of interests: The author has no conflicts of interest.
About the Authors
Sherif M. Elsaraj holds a B.Sc. in Biochemistry from Carleton University and a Masters of Science in Oral Biology from the University of Manitoba. Dr. Elsaraj is currently doing research towards a PhD in Temporomandibular Disorders and Craniofacial Pain at McGill University.
Mervyn Gornitsky is Research Director of the Department of Dentistry at the Jewish General Hospital. He is a Professor Emeritus at McGill University, Faculty of Dentistry, and Chief Emeritus of the Department of Dentistry at the Jewish General Hospital.