Face pain

I am currently treating a lady who gets intermittent stabbing pain towards her left lower jaw. She gets her pain when eating and intermittently and spontaneously throughout the day. She has seen a neurologist, dentist, physio and chiro and no one has diagnosed her condition. She has had some success with physio with her episodes decreasing in frequency and also with a night splint to stop her grinding her teeth. I have been unable to reproduce her pain when checking both her TMJ and cervical area. The only way her pain is reproduced in the clinic is by her sliding her tongue over the back of her teeth (?tmj movement).

Any ideas?

When we talk about the facial pain we should have to focus our attention over the pain sensitive structures. These possible sources of pain on the face may be from the teeth, gums, sinuses, temporomandibular joints, jaws and eyes. Any disorder or disease of these structures may cause the pain on face.

Facial pain is also caused by specific neurological disorders. These are trigeminal neuralgia, trigeminal nerve lesions, post herpetic neuralgia, cluster headaches (migranous neuralgia, Horton’s neuralgia), atypical facial pain (most probably considered to be somatic equivalent of depression), giant cell arteritis (cranial arteritis, temporal arteritis), tension headache and migraine.

Some times myofascial pain syndrome of neck shoulder and face muscles may mimic the other disorders of pain on the face. Ear and temporal mandibular joint pain may be due to due to the myofascial pain syndrome of lateral pterygoid, masseter (deep), sternocleidomastoid, Medial pterygoid. Eye or eye brow pain may be due to sternocleidomastoid (sternal), temporalis splenius cervicis, masseter (superficial), sub occipital group, occipitalis, orbicularis occuli, trapezius. Cheek and jaw pain may be due to sternocleidomastoid, masseter (superficial), lateral pterygoid, trapezius, masseter (deep), digastric, medial pterygoid, platysma, orbicularis occuli, zygomaticus major. Tooth ache may be due to the temporalis, masseter (superficial), digastric, frontal head ache may be due the sternocleidomastoid, semispinalis capitalis, frontalis, and zygomaticus major.

So when an appropriate cause is identified, a suitable management plan is made to treat the concerned disorder.

Can you be a bit more specific on whether she can reproduce the lower jaw pain by rubbing tongue on the upper or lower teeth? Also can you comment on what treatment approach you have done already that has lead to the reduction in episodes. This might assist to give more light to a continued treatment plan.

Perhaps a second dental opinion might also be of assistance as I have had this when eating intermittently due to worn enamel on the surface of a back molar. This simple became sensitive. Maybe the night splint is letting this slowly heal and that is leading to the reduction in painful episodes?

I'm not certain whether she is rubbing her tongue over her top or bottom teeth. What's the significance there?

I've worked on the TMJ (mainly distraction mobs), trigger point release through masseter etc, scalenes, SCM, traps, mobs to upper cervical. However, I am unable to reproduce her pain!


A second dental opinion sounds like a good idea at this stage.

thanks

If the pain is on the bottom jaw when rubbing the top teeth then maybe there is some referral happening. If it is only painful when rubbing over the bottom teeth, i.e. the painful area, then maybe the pain is local to the area being rubbed?

This problem sounds like a branch of the facial nerve is being irritated. Deep massage along the path of the branches around the TMJ, ear, and cheek can be of assistance. Using the finger (patients) inside the cheek to provide a stretch may help. Trigger point dry needling has also been useful (not acupuncture), when used into the facial muscles.

hi guys
i feel a detailed assessment of the patient is needed to come to a definite diagnosis.her posture,eg forward head posture,any maloclusion of teeth,recent dental problems,ear infections,tender points on palpation,parafunctional behaviours,psychological factors,stress in life,24 hour behaviour of pain,eg whether pain is at early morning-which gives clue to nocturnal teeth grindingwhile asleep.

U made a nice point there Sherly.However, the first post revealed that the pt had been seen by the dentist and i think, was referred to PT to manage.u see, gliding the tougue on the frontal surface of cannine would put the maticatory muscles in sustained contraction eccentrically and this could result in approximation of the TMJ and tension on already inflamed surrounding paraarticular tissues and pain as eventual result.A more detailed assessment might lead u to the diagnosis and the therapy required..merry xmas guys.yelufem.