Objectives

On reviewing this case scenario, the reader should appreciate that there are important differences between acute and chronic myofascial disorders in the orofacial region. Most acute muscle or tendon pains can be treated by the general dentist. Chronic musculoskeletal pains tend may have a more complex aetiology and referral to a multi‐disciplinary setting may be more appropriate.

Introduction

A 28‐year‐old Caucasian female patient was referred to the orofacial pain clinic by her general dental practitioner for investigation of persistent dental and facial pain in the left midface area.

Chief Complaint

She described her pain as a persistent nagging discomfort in the upper left posterior teeth, with radiating pain into the left ear at times. Her dental/facial discomfort was present on a continuous basis, but intensity varied between moderate and severe. With higher levels of pain intensity, she also experienced intermittent sharp, stabbing pain that varied in location through the left midface and left hemicranial area. Over a period of time movement of the lower jaw had gradually become painful and restricted. Proprietary analgesics like ibuprofen and acetaminophen (paracetamol) did not alleviate her discomfort. The persistent pain resulted in difficulties in getting to sleep and maintaining sleep.

A review of her history indicated that the patient had been involved in a road traffic accident 12 months earlier. Immediately after the accident she experienced pain in her neck and shoulders bilaterally. But over time, the pain seemed to intensify in the left midface area.

Previous treatments included root canal treatment on the LL6 and replacement of restorations on the upper left first and second molars, in addition to a course of physiotherapy, anti‐inflammatories and muscle‐relaxant medications. As her facial pain became more persistent, her tooth site pain became more intense. But the intake of hot or cold drinks did not affect the intensity of her dental discomfort. Likewise, movement of the lower jaw for chewing or talking did not increase her dental pain despite the increase in her facial pain.

Medical History

There was no history of systemic illness prior to the road traffic accident. Subsequent to the accident the patient experienced sleep disruption, anxiety and depression, which she attributed to her chronic pain condition. She had been prescribed the selective serotonin reuptake inhibitor (SSRI) venlafaxine to alleviate these symptoms.

Dental History

This patient was a dental phobic who had a history of infrequent dental attendances, poor oral hygiene and previous extractions of lower left second and third molars under intravenous sedation. When her orofacial pain became intolerable some months after the accident, she sought advice from her general dentist who proceeded to provide root canal therapy on the LL6. He also replaced old restorations on the UL6 and UL7. Despite these dental procedures, her pain continued to increase over time.

Clinical Examination

The diagnosis of persistent orofacial pain complaints must be based on a detailed history and thorough clinical assessment of the head, neck and face (Table 2.1.1). Radiographs are an essential part of the dental assessment, but in themselves are not diagnostic (Figure 2.1.1). Failure to include the head and neck as part of the clinical examination increases the risk of an incomplete diagnosis or misdiagnosis.