C. Medical History

• Comorbid pain conditions: chronic tension-type headache, neck and shoulder pain, and low back pain diagnoses by her general practitioner.
• Allergies to nickel, perfume, and latex.
• No previous relevant hospitalizations or surgeries.
• No other known medical conditions.
• No head trauma.
• Regular check-up at her private general dentist.
• Third molars complicated extractions 20 years ago.
• No other major dental treatments.

D. Psychosocial History

• Divorced, one child age 18 years old living at home.
• Teacher at a primary school part time.
• At present on sick leave due to the pain.
• Middle socio-economic status.
• No sport activities or exercise.
• Poor sleep quality and quantity.
• Pain is highly disabling, but moderately limiting (GCPS).
• Moderate to severe limitations in chewing tough food, hard bread, open wide enough to bite from a whole apple, talk, and sing (JFLS).
• Report of some parafunctional activity during daytime, such as some of the time tense muscles without clenching, place tongue between teeth, hold the jaw in rigid or tense position, and sustained talking (OBCL).
• Moderate symptoms of anxiety (GAD-7), depression (PHQ-9), and physical (PHQ-15).

E. Previous Consultations and Treatments

• Stabilization splint used during sleep with no effect on pain.
• Analgesic medication (over the counter) with paracetamol (acetaminophen) 3 g and ibuprofen 1200 mg 6–7 days per week provided minor pain relief.
• Physiotherapy due to neck and shoulder pain gave partial and temporary pain relief.
• Acupuncture and craniosacral therapy attempted several times, but with only minor pain relief.

F. Extraoral Status

General and face

• Normal appearance and BMI within normal limits.
• No asymmetries, swelling, or redness.

Neurologic findings

• No neurologic abnormalities upon screening.

Somatosensory and motor function

• No somatosensory or motor function abnormalities.

Temporomandibular joint

• No noise/sounds on standardized palpation.
• No pain on movements or standardized palpation.

Masticatory muscles

• Bilateral familiar masseter pain upon palpation with spread within the muscle (but not beyond).
• Bilateral familiar temporalis pain upon palpation, also familiar to her headache.

Jaw movement capacity

• Opening movement: straight. Pain-free opening: 42 mm. Maximum unassisted/assisted opening: 44/46 mm. Bilateral familiar masseter and temporalis pain.
• Lateral movements: right excursion, 12 mm; left excursion, 10 mm. Bilateral familiar masseter and temporalis pain.
• Protrusion: 10 mm. Bilateral familiar masseter and temporalis pain.

Neck and shoulders

• Pain on palpation of bilateral trapezius, splenius, and sternocleidomastoid muscles.

G. Intraoral Status

Soft tissues

• Negative.

Hard tissues and dentition

• Full arch dentition (28 teeth), few restorations, wear grade 1 and 2. No dental caries or periodontal disease.

Occlusion

• Sagittal: neutral. Horizontal overlap 3 mm. Vertical overlap 2 mm. No midline deviation.

Saliva

• Normal quantity and quality.
• Good oral hygiene.

H. Additional Examinations and Findings

• Generalized musculoskeletal pain conditions was ruled out.

I. Diagnosis/Diagnoses

DC/TMD

• Myalgia
  • subtype myofascial pain.
• Headache attributed to TMD.

ICHD-3 beta

• Chronic tension-type headache (Headache Classification Committee of the International Headache Society (IHS), 2013).

J. Case Assessment

• From the history and the physical examination it is revealed that the patient has suffered from chronic pain for several years in the jaw and the head. The pain and headache, which is always present, varies in intensity and is worsened by jaw movements, jaw functions, and jaw parafunctions and thereby fulfills the criteria for the common pain-related TMDs: myalgia and headache attributed to TMD. The pain also spreads to other anatomical structures (myofascial pain). Several comorbid pain conditions exist. The etiology of TMD is multifactorial. Risk factors of relevance in this case are gender and age, but also the comorbid pain conditions, the poor sleep, and psychosocial status, of which there are notably indications of distress.
• Several treatments have been attempted, but with no or minor effect on the pain. Analgesics provide minor pain relief; however, risk of medication-overuse headache exists due to the high intake of paracetamol and ibuprofen.

K. Evidence-based Treatment Plan including Aims

• The overall aims are to reduce the pain level and improve quality of life. Owing to the complexity, multimodal management is required.
• First management steps are information, counselling, and education, including tailored self-care program and approaches (exercise, sleep hygiene, awareness of jaw posture, etc.), but also instruction and monitoring of physiotherapy exercises self-performed (jaw stretching, relaxation, heat and/or cold (diathermy), and massage). Discontinue oral splint usage since no effect on pain levels.
• Inclusion of psychological therapy and pain support group are highly relevant.
• Pharmacological switch from paracetamol and NSAIDs to low-dose tricyclic antidepressants (TCAs) could also be relevant, this in cooperation with her general practitioner. TCA drugs are secondary analgesics. When a TCA is used in the management of chronic pain it is of great importance that sufficient high doses are used for a sufficient amount of time. If TCA treatment is chosen, monitoring TCA serum levels can be considered due to the individual variations in metabolism and diurnal levels, and so on. Other management options could include topical NSAID and hypnosis.

L. Prognosis and Discussion

• Moderate to good prognosis provided good patient cooperation and high-intensity, multimodal management approaches, including both the physical (Axis I) and the psychosocial (Axis II) factors that must be addressed.
• Tailored self-care program requires monitoring and adjustments as needed.
• The oral splint device does not provide pain relief, and since there are no signs of bruxism discontinuation is recommended.

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