A: Joint Pain

Case 2.1

Arthralgia

Per Alstergren

A. Demographic Data and Reason for Contact

• Caucasian woman (Figure 2.1), 29 years old, referred to orofacial pain specialist from ENT specialist for pain in front of and in ear left side. ENT examination found no reason to suspect ear pathology.

B. Symptom History

• Today: sharp pain in front of left ear at some occasions on mouth opening. Sometimes minor pain on chewing. No resting pain and pain fades away quickly after each occurrence. Pain occurs more frequently in the mornings but may occur throughout the day.
• Large mouth opening (yawning, singing) elicits pain but the patient does not know any factor that can relieve the pain.
• Pain intensity varies between 0 (at rest) and 7 (on mouth opening) on a 0–10 numerical rating scale (NRS). No headache. No neck pain. No occlusal changes.
• Characteristic pain intensity 16 (NRS 0–100), current pain intensity 0 (0–10 NRS), pain-related disability 30 (NRS 0–100; GCPS).
• JFLS reveals limitation in mouth opening and singing. Infrequent daytime parafunctions (chewing gum, clenching) according OBCL.
• Debut 4 months ago for unknown reason. The pain condition has increased somewhat since the debut; occurs more often today. Ten years ago a history of clicking in the left jaw, but this went away about 2 years ago. Trauma to right cheek and head after fall from horse 3 years ago. Initial pain and decreased mouth opening, the trauma thereafter resolved by itself in 1 week; no medical attention was sought.

C. Medical History

• Hypothyreosis, stable with Levaxin® medication.
• No allergies.

D. Psychosocial History

• Unmarried, lives together with boyfriend, no children. Happy with home situation.
• Sings in a choir two times a week.
• Works as an administrative secretary in a computer game company. Very satisfied with work situation, although often stressful work tasks in periods. Frequent computer work.
• Exercises regularly at a gym.
• Describes herself as a calm person with good stress management. Normal scores for depression (PHQ-9), no anxiety (GAD-7). No physical symptoms (PHQ-15) and moderate level of stress (Perceived Stress Scale (PSS)-10). Good sleep quality (Pittsburgh Sleep Quality Index (PSQI)).
• GCPS grade I; that is, low intensity, low disability.
• No smoking, little alcohol consumption.

Previous Consultations and Treatments

• General practitioner (dentist) tried nonsteroidal anti-inflammatory drug (NSAID) for 2 weeks. So far unclear indication; basically no effect. Referral to ENT for ear pain.
• ENT specialist excluded ENT condition. Referral to orofacial pain specialist.

Extraoral Status

Asymmetries

• None.

Swelling or redness

• None.

Somatosensory abnormalities

• Maxillary branch on left side shows hyperesthesia for touch and cold. Pinprick: normal findings (compared with the right side).
• Normal findings for the other two branches of the trigeminal nerve on the left side (compared with the right side) regarding touch, cold, and pinprick.

Temporomandibular joint

• No palpation pain.
• Brief familiar pain in left TMJ on maximum mouth opening (48 mm).

Masticatory muscles

• Familiar palpation pain in masseter muscle and temporalis insertion, left side.

Jaw movement capacity

• Maximum unassisted mouth opening 48 mm, laterotrusion to the right 9 mm and to the left 14 mm, protrusion 11 mm.
• Lower jaw deviates to the left on maximum mouth opening and protrusion.

Neck

• Normal movement capacity; no pain on movement or palpation.

G. Intraoral Status

Hard tissues and dentition

• Complete dentition with few and minor fillings.

Occlusion

• Stable with bilateral contacts on molars and premolars.

H. Additional Examinations and Findings

• None needed at this point.

I. Diagnosis/Diagnoses

DC/TMD

• Arthralgia in the left TMJ.
• Myalgia of the masticatory muscles.

J. Case Assessment

• Intermittent and rather intense pain on mouth opening in the left TMJ. Painful mouth opening does not elicit prolonged TMJ pain or pain at rest. Muscular palpation pain on the same side is interpreted as local sensitization; no other indications of a muscle tension problem.
• Anamnestic information gives rise to a suspicion of disc displacement without reduction in the left TMJ, but it is so far unclear to what extent that a possible disc displacement contributes to the current pain. In summary, most likely a mechanically induced nociceptive pain in the left TMJ, possibly related to a disc displacement without reduction and perhaps also the trauma to the right side of the face (implies trauma to left TMJ). No specific clinical signs of arthritis (prolonged pain, pain at rest, pain on movement, pain on loading, occlusal changes, swelling, etc.).
• Very little psychosocial distress.

K. Evidence-based Treatment Plan including Aims

• Counselling and patient education. Aims: to increase knowledge and understanding, to reduce anxiety and to correct expectations.
• Jaw exercises. Aims: increase physical activity in the masticatory system to reduce pain-eliciting factors, improve coordination, reduce arthralgia and myalgia.
• Stabilization appliance. Aim: reduce morning time increase in pain frequency by unloading the joint and by altering the sensory input during sleep.

L. Prognosis and Discussion

• The prognosis is good, both due to a rather short duration of the pain problem and due to the low characteristic pain intensity, pain-related disability, and psychological distress.

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