Heather Shepard: A 52-Year-Old Editor With Aching Jaw Pain and a Clicking Sensation





Learning Objectives





  • Learn the common causes of facial pain.



  • Develop an understanding of the unique anatomy of the temporomandibular joint.



  • Develop an understanding of the sensory innervation of the face.



  • Develop an understanding of the causes of facial pain.



  • Develop an understanding of the differential diagnosis of facial pain.



  • Learn the clinical presentation of temporomandibular joint pain.



  • Learn testing options to diagnose facial pain.



  • Learn how to use physical examination to diagnose facial pain.



  • Develop an understanding of the treatment options for the various types of facial pain.



Heather Shepard





Heather Shepard is a 52-year-old editor with the chief complaint of “jaw pain that radiates into the ear.” Heather was a longstanding patient and was one of the most uptight people that I had ever met. If you looked up “tense” in Wikipedia, you would see a picture of Heather. Over the years I had seen Heather for tension-type headaches, peptic ulcer, dysfunctional bowel, and insomnia. Stress had certainly taken its toll on Heather’s health. Today, Heather was complaining of pain in her jaw. “Doctor, it feels like there is something wrong with my jaw. It is always clicking, and it hurts when I open and close my mouth.” Heather went on to say that the pain was really driving her crazy. “It seems like I wake up with an achy jaw and by the end of the day, I just want to scream. It feels like someone hit me in the jaw with a baseball bat, like there should be a great big bruise there, but I look and there is nothing to see. I went to the dentist to see if there was something wrong with my teeth. The dentist took one look and said that I was grinding my teeth. The dentist then asked me if I was upset about anything. If I kept grinding my teeth, I would end up with dentures. That really made me mad. Like this is all in my head. So, I told her ‘thanks, but no thanks,’ and got the hell out of there. You don’t have the name of a good dentist, do you?”


I asked Heather how long she had the jaw pain and she said, “You know, I’ve had the headaches you treated me for about as long as I can remember, but this jaw pain has come on gradually over the last 5 or 6 months. I can’t really figure out what brought the pain on, but it is really driving me crazy.” She said that other than the tightness around her head and her neck ache, she did not have any other symptoms that went along with her jaw pain.


I asked Heather if she had identified anything that triggered her jaw pain and she immediately shook her head no. I asked Heather if she had any other symptoms that went along with her jaw pain and she said that when she yawned or opened her mouth very wide, she would feel a clicking sensation. I asked if she was having any associated neck pain, and Heather said, “By the end of the day, I just want someone to give me a neck massage. I feel like the neck and headaches and jaw pain all go together. I feel like I am always clenching my teeth. I don’t know why. I guess it’s just become a habit.”


I asked her what made it better, and she said, “I’ve tried all of the usual over-the-counter medications like Excedrin Migraine and Advil, but they really upset my stomach, so I can’t take them very often. Remember those ulcers? Sometimes a heating pad and a glass of wine seem to help a little.”


I asked Heather to use one finger to point at the spot where it hurt the most, and she pointed to her temporomandibular joint (TMJ) on the left. I asked her what the pain was like: an ache, sharp, stabbing, burning? She immediately said, “It’s a deep, achy kind of feeling. Once in a while when my jaw clicks, I can feel it up in my ear, but not every time.” I asked whether the jaw pain was on both sides or just one side, and she said it was always on the left, never on the right. I asked Heather from the time that she knew she was going to get the jaw pain until the time it was at its worst, was it a period of seconds, minutes, or hours. She responded, “It is always at least a few hours to a day before it is at its worst. But most days it is there when I wake up. It seems to get worse as the day goes on. As you know, my sleep has never been great, but this jaw pain sure hasn’t helped.”


On physical examination, Heather was afebrile. Her respirations were 16 and her pulse was 78 and regular. Her blood pressure was 126/80. There were no cranial abnormalities, and her eye, nose, and throat examination were completely normal, as was her fundoscopic examination. I could feel no mandibular mass, but a click was present on palpation of the TMJ when I had Heather open and close her mouth. I was shocked at the condition of Heather’s teeth. Heather had broken off the occlusal surfaces of the teeth, presumably from bruxism ( Fig. 15.1 ). Heather’s cervical paraspinous muscles were tender to deep palpation, but no myofascial trigger points were identified. Her cardiopulmonary examination was normal, as was her thyroid. Her abdominal examination revealed no abnormal mass or organomegaly, and no rebound tenderness was present. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. A careful neurologic examination of the upper and lower extremities revealed no evidence of weakness, lack of coordination, peripheral or entrapment neuropathy, and her deep tendon reflexes were normal. No pathologic reflexes were identified. Heather’s mental status exam was within normal limits, but I was again struck by the high level of anxiety Heather displayed.




Fig. 15.1


Damage to the occlusal surfaces secondary to bruxism.

From Johansson A, Omar R, Carlsson GE. Bruxism and prosthetic treatment: a critical review. J Prosthodont Res . 2011;55(3):127–136 [Fig. 10]. ISSN 1883-1958, doi.org/10.1016/j.jpor.2011.02.004 , www.sciencedirect.com/science/article/pii/S1883195811000387


Key Clinical Points—What’s Important and What’s Not


The History





  • History of episodic tension-type headache



  • Unilateral jaw pain



  • Opening and closing of the mouth causes a clicking sensation with pain that radiates into the ipsilateral ear



  • Jaw pain associated with nuchal pain and headache



  • Character of the pain of headache was aching in nature, without throbbing



  • Significant sleep disturbance



  • Patient denies fever or chills



  • Patient admits to clenching the jaw



  • Headache associated with work stress



The Physical Examination





  • Patient is afebrile



  • Clicking of the TMJ with opening and closing of mouth



  • Broken teeth thought to be secondary to bruxism (see Fig. 15.1 )



  • Normal fundoscopic exam



  • Examination of the cranium is normal



  • Neurologic exam is normal



  • Tenderness of the paraspinous muscles without myofascial trigger points



Other Findings Of Note





  • Normal cardiovascular examination



  • Normal pulmonary examination



  • Normal abdominal examination



  • No peripheral edema



  • Normal upper and lower extremity neurologic examination, motor and sensory examination



What Tests Would You Like to Order?


The following tests were ordered:




  • Radiographs of the TMJs



  • Arthrography of the TMJs



  • Magnetic resonance imaging (MRI) of the TMJs



Test Results



Mar 21, 2022 | Posted by in PAIN MEDICINE | Comments Off on Heather Shepard: A 52-Year-Old Editor With Aching Jaw Pain and a Clicking Sensation
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