History

Fiona is a 30-year-old schoolteacher and you have known the family for years. She phones your practice because she is in pain but due to school commitments cannot attend during the day. She is seen by you in your evening emergency space.

She is complaining of pain from her left cheek area. She said the pain began spontaneously about 6 weeks ago. It was intermittent but is now becoming more frequent. As her students are approaching their GCSE exams, she was busy at school and could not afford time off work to seek advice. Today, however, the pain has become so bad that she can ignore it no longer. She described it as being episodic and sharp, stabbing severe pain that lasts for no more than a few seconds – ‘it makes my eyes water!’. It can arise spontaneously but she notices it more when she washes her face or puts on make-up. She now avoids touching a certain area of her face. She said that she had had similar symptoms about 9 months ago which were not as severe and ‘went away’. She gets episodes of the sharp pain three or four times a day but today it is much more intense and frequent.

She also has pain brought on by brushing her teeth with cold water and eating cold foods such as ice cream, and her teeth ache for a while after eating or drinking extremes of temperature.

She has not taken any analgesia because she said that she suffers from ‘heartburn’. You have suspected for some time that Fiona is bulimic and you have been concerned about acid erosion of her teeth, particularly on the palatal surfaces of the upper incisors. You have attempted to discuss this with Fiona but she denies making herself sick. About a month ago you discussed with her the possibility of root canal treatment to an upper left molar tooth because this tooth had become exquisitely sensitive to hot and cold. There was a large area of exposed palatal root of the upper left second molar. She, however, declined because she was too busy and wished to defer any definitive treatment until school broke up for the summer holidays. She said that her symptoms were not exacerbated by stress or by physical activity. Fiona is married; she has two young daughters and lives with them and her husband, who is currently in full-time employment.

She volunteered that she had been to her doctor recently because she feels weepy and stressed. She has the pressure of her job and is also worried about her husband, who is a builder, because she fears that his business is under threat as a result of the economic climate. You have in the past asked her about the erosion on her teeth but she has consistently denied any untoward habits. You know that she has had a history of increased alcohol intake in the past but she stopped drinking alcohol when she became pregnant with her first child and has not consumed alcohol since.

She takes thyroxine for an underactive thyroid. She is otherwise fit and well and attends gym classes three evenings a week.

Examination

On examination, there was a normal range of mouth movement in the vertical and lateral directions. You examined the TMJs for tenderness and there was no tenderness on lateral palpation in the area immediately in front of the ear, on intra-auricular palpation via the external auditory meatus or on manipulation of the mandible to a retruded position. There was intermittent soft clicking in the left TMJ but no crepitation.

She did have signs of parafunction in that she had ridging of the inside of her cheeks and scalloping of the lateral border of her tongue. There was no obvious abnormal wear faceting and there was no obvious attrition of her teeth. There was, however, erosion of the enamel on the palatal surfaces of her upper teeth, especially the incisors and molars. The palatal root of the upper left second molar was exposed and there was approximately 7 mm of gingival recession. There was no masticatory muscle tenderness. You examined the masseter and temporalis muscles by digital palpation and you examined the lateral pterygoid against resistance.

When you examined her occlusion she appeared to have centric relation occlusion; there was no premature contact and there was no slide from centric relation to centric occlusion. On lateral excursions of the mandible she had canine guidance and there were no obvious interferences on the working or non-working side. She had good oral hygiene; there were no calculus or plaque deposits. She had heavily restored posterior teeth but no teeth were tender to percussion although she said that the upper left second molar felt ‘slightly different’. She had generalised sensitivity due to gingival recession and the erosion on the palatal surfaces of her upper teeth; this was particularly noticeable around the region of the upper left first molar.

Radiographic Examination

In view of the fact that she had heavily filled posterior teeth and because you had not taken bite-wing radiographs for about 18 months, you took right and left bite-wing radiographs and a periapical of UL7 at the time of her examination. These radiographs showed her restorations to be in good condition. There was no primary or recurrent caries and no apical pathology. There were no obvious deposits of calculus and the bone level appeared normal apart from the upper left quadrant where there was slight horizontal bone loss.

Differential Diagnosis

Tunnel vision is dangerous! It is your responsibility when diagnosing a patient with a history of facial pain to consider all possibilities.

Let us consider all possible sources of Fiona’s symptoms:

• Dental (pulpitis, pericoronitis, apical periodontitis)
• Fractured tooth
• Temporomandibular disorder (TMD)
• Neuralgic pain
• Sinus pain
• Ear infection
• Headache
• Soft tissue
• Cervical spine pain
• Salivary glands
• Atypical facial pain
• Referred cardiac pain
• Multiple sclerosis
• Central lesion
• Tumour (acoustic neuroma)
• Ophthalmic
• Dry socket
• Trauma.

Let us deal with the list in reverse order.

It should be possible to eliminate most of these potential diagnoses by history taking and discussion. Her symptoms are too specific for them to be coming from an ophthalmic problem, although if you have any doubt you should suggest that she sees her optician to have her eyesight tested.

Dry socket and trauma can be immediately excluded in the absence of any germane history of either a blow or a recent dental extraction.

Had there been a central lesion or an acoustic neuroma, you would have expected other symptoms such as possible involvement of the cranial nerves and headache or continual facial pain. You thought about a tumour such as an acoustic neuroma but this would, however, have been accompanied />