Kathy’s Story
Kathy is a 70-year-old woman who had never in life experienced jaw pain nor any significant headaches. That all changed when she awakened one morning with left-sided jaw pain. Two days later, the pain spread to her left-side teeth. In the coming days, the pain spread to the right side of her face and throughout her entire head.
Kathy initially sought care from her dentist, who ruled out dental disease and attributed the pain to a temporomandibular disorder (TMD). She also sought care from her primary care physician who seconded TMD as the cause of her pain. She was treated with acetaminophen, ibuprofen, tizanidine (a muscle relaxant), and a nightguard, none of which helped.
At the time she presented to our office, Kathy had been suffering for 3 weeks. She described a “horrible squeezing pain” throughout her head and face, along with difficulty chewing and opening her mouth. Her husband, who accompanied her to the appointment, stated she was an entirely different person the past few weeks – not the energetic, happy person he had known. She was clearly suffering.
Kathy’s Examination
During her examination, Kathy could not tolerate the lightest touch to her TMJs. She also recoiled from light touch to her temporalis, masseter, sternocleidomastoid, and occipital muscles. (In other words, she was experiencing generalized allodynia throughout her head and neck). Her mandibular range-of-motion was markedly limited, with an interincisal opening of only 20mm (normal mouth opening is 40+mm). A panoramic radiograph of Kathy’s face was unremarkable.
Does the Story Add Up to a TMJ Issue?
Most patients come to our practice with a presumed TMD (i.e., musculoskeletal jaw pain or dysfunction). And of those patients, most do, in fact, have a TMD. However, a sizable minority do not. Rather, they are suffering from a TMD mimicker.
Many conditions can mimic TMDs – referred neck pain, migraine, tooth pain, neoplasm, even referred cardiac pain. Sometimes these mimickers are picked up on the physical examination or on imaging. But most of the time, they are recognized because something in the patient’s story doesn’t add up to a TMD.
Kathy’s Assessment
Was Kathy’s story consistent with pain due to a TMD?
She had limited ability to chew and open her mouth. Her TMJs and jaw muscles were painful to palpation. These data points seemingly point to a TMD condition. But what about the rest of the story?
Remember, Kathy was a 70-year-old woman with no prior history of face or head pain. Older people can strain or sprain their jaws. They can develop pain and functional issues due to TMJ osteoarthritis. But the quick and unprovoked onset of Kathy’s pain, the diffuse nature of the pain throughout her head and face, and the extreme resultant suffering was simply not consistent with a musculoskeletal jaw problem. This appeared to be a case of a TMD mimicker.
The two main items on Kathy’s differential diagnosis were intracranial neoplasm (brain tumor) and temporal arteritis.
Temporal arteritis
Temporal arteritis (also known as “giant cell arteritis”) is a condition marked by inflammation of medium- and large-sized blood vessels, particularly in the head. It rarely occurs before the age of 50 and is most common in older women of Northern European descent. It should always be considered in the differential diagnosis of new-onset headache in an older person. Other classic symptoms include jaw claudication and non-specific systemic illness (such as low-grade fever and malaise).
“Jaw claudication” refers to pain or fatigue when chewing. The arteries supplying the jaw muscles are narrowed by inflammation, leading to painful muscular ischemia. This can easily be mistaken for a more typical muscular jaw problem.
Around 25% of patients with temporal arteritis develop transient visual symptoms such as diplopia (which can result from ischemia of the oculomotor muscles) and close to 10% develop permanent blindness in at least one eye (which results from ischemia of the optic nerve). Blindness may occur suddenly – hence, temporal arteritis is considered a medical emergency.
Temporal arteritis can be definitively diagnosed by either biopsy or ultrasonographic examination of the temporal artery.
Oral steroids are the mainstay of treatment. Urgent initiation of steroids is necessary to reduce the risk of blindness. Patients often need to stay on steroids for one year or longer.
Kathy’s Treatment
Given the suspicion of temporal arteritis, Kathy was immediately prescribed high-dose oral steroids. Further evaluations were scheduled with the help of her primary care physician. A head CT ruled out brain tumor. A temporal artery biopsy confirmed the diagnosis of temporal arteritis. Kathy reported feeling substantially better (“like a new person”) after a few days on the steroids. A rheumatologist assumed her care and will be managing her condition moving forward.
Summary
While TMDs are the most common causes of facial pain, they are not the only causes. We must remember that TMDs are musculoskeletal conditions – not substantially different from low back or knee pain conditions. Before diagnosing or treating a facial pain concern as a TMD, we need to ask, “Does this presentation make sense in the context of a musculoskeletal condition?” If it doesn’t, we need to consider the possibility of a TMD mimicker, such as temporal arteritis. Orofacial Pain specialists are uniquely trained to assess for such a possibility.
Dr. John Dinan is a Diplomate of the American Board of Orofacial Pain and the American Board of Dental Sleep Medicine. He practices in our New York City and Springfield, NJ, locations.
