Heather Shepard

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.

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, https://doi.org/10.1016/j.jpor.2011.02.004 , http://www.sciencedirect.com/science/article/pii/S1883195811000387

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

What Tests Would You Like to Order?

The following tests were ordered:

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  Radiographs of the TMJs

  
  
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  Arthrography of the TMJs

  
  
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  Magnetic resonance imaging (MRI) of the TMJs