- Email: [email protected]
Mandibular pain as the initial and sole clinical manifestation of coronary insufficiency: report of case
CLINICAL
REPORTS
11. W arin, R .P . E p ith elio m a fo llo w in g lich en p la n u s of the m o u th . Br J D erm atol 72(8-9):288-291, 1960. 12. Jan n e r, M.; von M uissus, E.; a n d R ohde, B. L ichen p la n u s als fakultative prakanzerose. D erm atol W ochenschr 153(18):513-518, 1967. 13. F ulling , H .J. C ancer developm ent in oral lichen pla n u s: a follow -up study o f 327 patients. A rch Der m atol 108(5):667-669, 1973. 14. C ernea, D.; K uffer, R.; a n d B rocherion, C. L ’ep ith e lio m a sur lich en p la n buccal. A ctual O dontostom atol 25:473-490, 1971. 15. Silverm an , S., an d G riffith , M. Studies on oral lichen p la n u s: fo llo w -u p on 200 p atien ts, clinical characteristics, a n d associated m alignancy. O ral Surg 37(5):705-710, 1974. 16. P in d b o rg , J.; D aftary, D.; an d M ehta, F. A follow -up study o f 61 oral dysplastic precancerous lesions in In d ia n villagers. O ral S urg 43(3):383-390, 1977. 17. V on S chettler, D., an d K oberg, W. Interessante E inzelbeobach tu n g en lich en ru b er p la n u s der M u n d sch le im h a u t m it m alig n er E n tartu n g . Zentralbl C hir 95(37): 1101-1108, 1970. 18. M u rti, P .R., an d others. M alig n an t p o te n tia l of oral lichen p lan u s: observations on 722 p atien ts from India. J O ral P a th o l 15(2):71-77, 1986. 19. P ogrel, M.A., an d W eldon, L .L . C arcinom a a risin g in erosive lichen p la n u s in the m id lin e d o r sum of the tongue. O ral Surg 55(l):62-66, 1983. 20. Silverm an, S.; G orsky, M.; an d Lozada-N ur, F. A prospective follow -up study of 570 p atien ts w ith oral lichen p la n u s: persistence, rem ission, an d m a lig n a n t association. O ral S urg 60(l):30-34, 1985. 21. Kovesi, G ., an d Banoczy, J. Fo llo w -u p studies
in oral lichen planus. In t J O ral S u rg 2(1): 13-19, 1973. 22. Y esudian, P., an d R aghuveera, R. M alig n an t tran sfo rm atio n of hy p ertro p h ic lichen planus. In t J D erm atol 24(3): 177-178, 1985. 23. Vas’kovskaia, G .P ., and others. D evelopm ent of cancer in lichen p la n u s foci of the o ral an d verm ilion b o rd er m ucosa. S tom ato lo g iia (M osk) 60(3):46-48, 1981. 24. H o lm stru p , P., and Pindborg, J. E rythroplakic lesions in re la tio n to oral lichen p la n u s. Acta Derm Venereol (S uppl) (Stockh) 59(25):77-84, 1979. 25. Shklar, G . L ichen plan u s as a n oral ulcerative disease. O ral S urg 33(3):376-388, 1972. 26. C aw son, R.A. T re a tm e n t of oral lichen p la n u s w ith betam ethasone. Br Med J l(5584):86-89, 1968. 27. V on A bram ova, E.J. L ichen ru b er p la n u s der m u n d h o h le. D erm atol W ochenschr 154(14):315-323, 1968. 28. G rin sp a n , D., an d others. N otre experience sur le lichen ru b er p la n u s de la m u q u eu se buccale. Ann D erm atol Venereol 93(5-6):531-542, 1966. 29. A ltm an, J., and Perry, H .O . T h e variations and course of lichen planus. Arch D erm atol 84:179-191, 1961. 30. Sugar, I., an d Banoczy, J. U n tersuchungen bei prakanzerose der m undschleim haut. D tsch Zahn M und K eiferheilkd Zentralbl G esam te 30:132-140, 1959. 31. D echaum e, M.; Payen, J.; an d P irio u , J. Le lich en p la n isole de la m u q u eu se buccale: considera tions an ato m o clin iq u es d ’apres 50 observations d o n t 30 avec exam en h istologique. Presse M ed 65:21332135, 1957. 32. Scheurm an, H . Zur carcin o m en tsteh u n g au f lichen ruber. D erm atol W ochenschr 108:230, 1939. 33. M ontgom ery, D.S., and C ulver, G.D. L ichen
p lan u s of the m o u th alone. Br T D erm atol 41:45-50, 1929. 34. W illiger, F. L ichen ru b er p la n u s a n d karzinom . V jschr f Z ah n h 1:58-61, 1924. 35. K aplan, B., and Barnes, L. O ral lichen planus an d sq u am o u s carcinom a: case re p o rt a n d u pdate of the literature. A rch O tolaryngol lll(8):543-547, 1985. 36. M ashberg, A., an d Meyers, H . A natom ic site and size of 222 early asym ptom atic oral squam ous cell carcinom as. C ancer 37(5):2149-2157, 1976. 37. Frazell, E.L ., an d L ucas, J.C . C ancer of the tongue: re p o rt of the m an ag em en t of 1,554 patients. C ancer 15(6): 1085-1099,1962. 38. D aniels, T .E ., and Q uadra-W hite, C. Direct im m unofluorescence in oral m ucosal disease: a diag nostic analysis of 130 cases. O ral S u rg 51 (1 ):38-47, 1981. 39. Laskaris, G.; Slavounou, A.; and A ngelopoulos, A. D irect im m unofluorescence in lichen planus. O ral S urg 53(5):483-487, 1982. 40. O gus, H .D ., an d Bennett, M .H . C arcinom a of the dorsu m of the tongue: a rarity o r m isdiagnosis. Br J O ral S urg 16(2): 115-124, 1978. 41. D om onkos, A.N.; A rnold, H .L .; and O dom , R.B. A ndrew s’ diseases of the skin: clinical derm atol ogy, ed 7. P h ilad e lp h ia , W. B. Saunders Co, 1982, p p 1068-1069. 42. L indelof, B., a n d E k lu n d , G. Incidence of m a lig n a n t skin tum ors in 14,140 patien ts after grenzray treatm en t for b e n ig n skin disorders. Arch Der m atol 122( 12): 1391-1395, 1986. 43. W aldron, C.A., an d Shafer, W .G. L eukoplakia revisited. C ancer 36(4): 1386-1392, 1975. 44. Shafer, W .G ., a n d W aldron, C.A. Erythroplakia of the oral cavity. C ancer 36(3): 1021-1028, 1975.
Mandibular pain as the initial and sole clinical manifestation of coronary insufficiency: report of case Barbara J. B atcheider, D M D D avid J. K rutchkoff, D D S , M S Jea n A m ara, D M D
A case of anginal pain limited to the mandible with secondary radiation of the pain to the neck and clavicular regions is presented. Although the pain was initially diagnosed as odontogenic in origin, fur ther historical workup suggested the suspicion of referred pain from coronary insufficiency. Immediate cardiac evalua tion confirmed the nature of the pain as angina. Important aspects involved with differential diagnosis of referred anginal pain are also discussed.
710 ■ JADA, Vol. 115, N ovem ber 1987
ardiac p a in (angina) is the m ost im p o rta n t early clinical m anifes tation of life-threatening coronary artery disease. P ro m p t detection, identifi cation, and ap p ro p riate m anagem ent of ang in a are essential in averting otherwise catastrophic sequelae (for exam ple, acute m yocardial infarction). A lthough an g in a usually appears as pain in the chest or left arm , the possibility of an g in a found solely as pain in the head and neck region should not be overlooked. Coronary insuf ficiency m ust be considered in the differ ential diagnosis of oral o r facial pain,
C
particularly after the m ore com m on local causes have been carefully checked and deemed unlikely. Report of case A 71-year-old, ap p aren tly healthy w hite m ale was exam ined by his dentist in A ugust 1985; he h ad vague, interm ittent p ain in the m andible of 1 to 2 m o n th s’ duration. T h e p a in was described by the p atien t as a “sensation of pressure, like a bad to othache” th a t occurred prim arily after eating and som etim es d u rin g peri-
CLINICAL
ods of exertion, such as playing a game of tennis. T he patient was edentulous in the maxilla and had only three remaining teeth, the two contiguous left m andibular prem olars an d canine. All teeth had apparently adequate full coverage. The canine and the second p rem o lar had previously been endodontically treated leaving the first premolar as the only rem aining tooth w ithout previous end odontic therapy (Fig 1). The patient’s pain was initially diag nosed as odontogenic in origin and was thought to be secondary to pulpal disease of the first premolar. T he patient was referred to an endodontist who performed endodontic treatment on the rem aining untreated tooth and referred the patient to the general practitioner for completion of care. During the next examination, the general practitioner noted that, in spite of the recent endodontic procedure, the patient’s pain was still present and had not changed significantly since comple tion of therapy 1 week earlier. T he patient was then referred to the departm ent of oral diagnosis for diagnostic consultation. Further questioning during exam ina tion disclosed that the pain seemed to stem from the left side of the mandible and often radiated to the patient’s back, shoulder, or clavicular region. There was no pain in the chest or arm. T he pain seemed to last approximately 30 minutes and then apparently subsided with rest. It was also disclosed that the first episode of pain had occurred almost 1 to 2 m onths earlier, primarily as a feeling of pressure in the patient’s mandible. Subsequently, however, the pain became progressively more severe and seemed localized to the left side of the mandible. Because the epi sodes seemed to occur m ainly after meals,
F ig 1 ■ Periapical film o f the p a tien t’s three rem aining teeth (mandibular left canine, first and second premolars) at the time o f the in itia l exam ination. T he pain was thought to be caused by p u lp al disease of the untreated first premolar, and the patient was subsequently referred for endodontic treatment.
REPORTS
Fig 2 ■ Periapical film s of rem aining mandibular left teeth plu s adjacent posterior edentulous bone taken after com pletion of endodontic therapy and placem ent of post. In view of findings, local disease was considered as an unlikely explanation for the patient’s pain.
the patient attributed the pain to a prob lem with his m andibular partial denture. In itia lly , the p a in caused only m ild discomfort and the patient sought consul tation with his general dentist who had been treating him. T he dental history was otherwise noncontributory. The patient had gout and hypertension, the latter co ntrolled adequately w ith diuretics. T he patient also had a history of transitional carcinoma of the renal pelvis in January 1981; a transurethral prostatectomy was performed in December 1981. Tissue analysis from this procedure confirmed the diagnosis of grade II tran sitional cell carcinom a of the bladder. Results of subsequent cytoscopic exami nations after surgery were negative for recurrence of carcinoma. In October 1984, the patien t had unrelated left indirect inguinal herniorrhaphy. O ther than his current m edication of diazide (25 mg daily), the patient’s medical history was otherwise noncontributory. Physical examination showed a moder ately overweight yet athletic-appearing ad u lt w hite male. Blood pressure was 148/78 mm H g (left arm, sitting). The pulse was 68 and regular. Extra- and intraoral examinations were noncontrib utory aside from a m axillary complete denture and a mandibular partial denture. Only three teeth remained of the natural dentition, all of which had been end odontically treated and restored with full crowns. Mild gingival inflammation was noted around the remaining teeth with b leed in g on p ro b in g . Pocket depths ranged from 2 to 4 mm. All other oral tissues were w ithin normal limits. Two additional periapical radiographs were obtained and interpreted as essen tially unremarkable (Fig 2). After consid eration of historical, clinical, and radiographic data, it was determined that local
factors could not adequately account for the patient’s reported m andibular pain. Because of the suspicion of occult coro nary insufficiency, the patient’s physician was contacted and asked to see the patient as soon as possible. T h e p a tien t was advised of the urgency of the situation and saw his physician the next m orning. Shortly thereafter, the patient was ad m itted to the hospital and underwent thorough cardiac evaluation. T he electro cardiogram (ECG) showed severe anterior wall injury and ischemia when compared with a normal ECG taken 1 year ealier (October 1984). Coronary angiography disclosed 90% occlusion of the left ante rior descending coronary artery. T his cor responded with the area on the ECG that showed ischemic changes. W ith com pletion of the diagnostic phase, the patient was treated with nitro glycerin paste, 1 in every 6 hours. He also received nifedipine (10 mg three times a day), hydrochlorothiazide (one capsule daily), plus nitroglycerin tablets to be taken as needed. T he patient reported that the mandibular pain subsided immediately after appropriate nitroglycerin medication. Currently the patient is being followed by the cardiologist on an outpatient basis to determine the adequacy of his thera peutic regimen. There still remains the future option of a surgical bypass proce dure depending on the progression of symptoms with current medication. Discussion
Angina pain was first described as a m an ifestation of coronary disease in 1802.' Today, angina is readily recognized and diagnosed when appearing in the usual clinical manifestation as classic angina pectoris; that is, with constricting substernal pain radiating to the left arm or
Batchelder-Krutchkoff-Amara : MANDIBULAR PAIN AS CORONARY INSUFFICIENCY ■ 711
CLINICAL
REPORTS
neck.2 A ngina is usually brought on by physical exertion, em otional upset, or ingestion of food. Classically, anginal pain is promptly relieved by rest or by s u b lin g u a l ad m in istration of n itr o glycerin. Early descriptions of anginal heart pain did not include reference to the fact that it could occasionally be found as referred pain to the face and jaw. More recently, pain in the head and neck has been rec ognized as a possible sign of heart dis ease.2 When angina is present as referred pain to the head or neck, the typical pat tern resembles that of pain in the chest and arm, radiating upward to the neck and into the angle of the jaw. This classic presen tation offers little d ifficu lty in recognition, especially if the facial pain occurs during exertion or excitement and has the sam e q u a lity as the thoracic discomfort it accompanies. In contrast, substantial diagnostic difficulties arise when cardiac pain occurs in the absence of any symptoms in the chest or left arm. In fact, it is rare for angina to be found as jaw or facial discomfort without pain in the chest or arm. When anginal pain is lim ited to the face or jaw, its true nature as referred pain or coronary insufficiency m ay be co m p letely overlook ed . T h e unfortunate result of such an oversight is lack of recognition of underlying heart disease. A secondary and less important consequence is inappropriate local dental treatment for a condition that has no rela tionship to dental disease. Many reports in the medical literature indicate that pain of cardiac origin may be referred beyond the chest to the jaws and teeth .2'4"7 A typ ical case is that reported by Bell8 in which angina was seen as sim ultaneous pain in the left shoulder and left side of the mandible. However, sole manifestation of cardiacrelated pain outside of the chest is appar ently uncomm on. In an analysis of 150 patients w ith anginal symptoms, Samp son and C heitlin3 report that 96% had chest pain. In 34% of the total cases, chest pain was the only manifestation of angina. In approximately one third of the cases, the angina radiated to the left arm and wrist as well. In 10% of the cases, pain
712 ■ JADA, Vol. 115, November 1987
radiated to the right arm and in 13% to the right wrist. In 22% of the patients studied, angina pain radiated to the neck and in 9% to the mandible. In 16%, angina pain was recognized as radiating to the back. Sole involvement outside the chest was uncomm on and was mentioned in only five cases of the 150 studied. Of these five, two had angina present as pain only in the neck, two with pain only in the left wrist, and one with pain only in the epigastrium. None of the 150 patients studied had jaw pain alone. Others4 have reported that in 18% of all cases, cardiac pain is localized solely to the jaw and teeth. However, there are few well-documented reports in the dental literature.9"11 A notable exception is the recent case reported by Edge12 in which angina was seen solely as pain of the soft palate. D entists have an im portant role as diagnosticians, especially with regard to pain of the head and neck region. It is important to remember that there is no single formula for the correct diagnosis of any unknown clinical problem. Further, cases involving the diagnosis of unusual or vague facial pain can be am ong the most difficult of diagnostic problems.13 When encountering clinical problems that are not adequately explained by local causes, it is the responsibility of the den tist to m ake correct assessm ents and appropriate referrals if necessary. T he examiners must approach each patient w ith an open m ind. A thorough and accurate historical database is imperative. An adequate history is as important, if not more so, than the clinical and radiographic components of the exam ination in determining the correct diagnosis. In this case, the key factors were: pain appeared first in one location (the left side of the mandible) and then radiated to the back and to the clavicular area; pain was brought on by exertion or a meal and subsided w ithin a rest period of 30 m in utes. These facts, coupled with a lack of findings to support a local cause, sug gested that observed pain was suspicious of coronary insufficiency. Appropriate m edical referral confirmed diagnostic suspicions, and the patient is now well
with prescribed treatment.
Conclusions There is no substitute for correct diagno sis regardless of the nature of medical or dental practice involved. The need for careful and thorou gh h istory takin g cannot be overemphasized. Careful con sideration of such w ill often reveal valu able information that w ill aid in making accurate diagnoses and performing appro priate treatment. O nly after a correct diagnosis is established can proper treat ment be instituted and optim al patient care be carried out.
-------------------- JSOA --------------------Dr. Batchelder is captain, Dental Corps, US Air Force. Dr. Krutchkoff is professor, department of oral diagn osis/p ath ology, School of Dental Medicine, University of Connecticut, Farmington, CT 06032. Dr. Amara is in private practice, Wethersfield, CT. Address requests for reprints to Dr. Krutchkoff. 1. Gorlin, R. Patho-physiology of cardiac pain. Circulation 32:138-144,1965. 2. Paine, R. Vascular facial pain. In A ilin g, C.C. I ll, and Mahan, P., eds. Facial pain, ed 2. Philadel phia, Lea 8: Febiger, 1977. 3. Sampson, J.J., and Cheitlin, M.D. Pathophysi ology and differential diagnosis of cardiac pain. Prog Cardiovasc Dis 13(6):507-531,1971. 4. B onica, J.J. T h e m anagem ent o f p ain w ith special emphasis on the use of analgesic block in diagnosis, prognosis, and therapy. Philadelphia, Lea Sc Febiger, 1953, p 1318. 5. Rushmer, R.F. Cardiovascular dynamics, ed 2. Philadelphia, W. B. Saunders Co, 1961, p p 225-226. 6. Mitchell, D.F.; Standish, S.M.; and Fast, T.B. Oral diagnosis/oral medicine. Philadelphia, Lea 8c Febiger, 1971, p 224. 7. Dalessio, D.J. W olf’s headache and other pain, N ew York, Oxford University Press, 1972, pp 38, 617. 8. Bell, W.E. Orofacial pain—differential diagno sis. Dallas, Dedeco, 1973, pp 197-200. 9. Matson, M.S. Pain in orofacial region associated w ith coronary insufficiency. Oral Surg 16(3):284-285, 1963. 10. N atkin, E.; Harrington, G.W.; and Mandel, M.A. A nginal pain referred to the teeth. Oral Surg 40(5):678-680, 1975. 11. Graham, L.L., and Schinbeckler, G.A. Orofa cial pain of cardiac origin. JADA 104(l):47-48, 1982. 12. Edge, C.J. A ngina pectoris presenting as pain of the soft palate. Br Dent J 158:335-336, 1985. 13. Norman, J.E. de. Facial pain and vascular dis ease: some clinical observations. Br J Oral Surg 8:138144, 1970.
REPORTS
11. W arin, R .P . E p ith elio m a fo llo w in g lich en p la n u s of the m o u th . Br J D erm atol 72(8-9):288-291, 1960. 12. Jan n e r, M.; von M uissus, E.; a n d R ohde, B. L ichen p la n u s als fakultative prakanzerose. D erm atol W ochenschr 153(18):513-518, 1967. 13. F ulling , H .J. C ancer developm ent in oral lichen pla n u s: a follow -up study o f 327 patients. A rch Der m atol 108(5):667-669, 1973. 14. C ernea, D.; K uffer, R.; a n d B rocherion, C. L ’ep ith e lio m a sur lich en p la n buccal. A ctual O dontostom atol 25:473-490, 1971. 15. Silverm an , S., an d G riffith , M. Studies on oral lichen p la n u s: fo llo w -u p on 200 p atien ts, clinical characteristics, a n d associated m alignancy. O ral Surg 37(5):705-710, 1974. 16. P in d b o rg , J.; D aftary, D.; an d M ehta, F. A follow -up study o f 61 oral dysplastic precancerous lesions in In d ia n villagers. O ral S urg 43(3):383-390, 1977. 17. V on S chettler, D., an d K oberg, W. Interessante E inzelbeobach tu n g en lich en ru b er p la n u s der M u n d sch le im h a u t m it m alig n er E n tartu n g . Zentralbl C hir 95(37): 1101-1108, 1970. 18. M u rti, P .R., an d others. M alig n an t p o te n tia l of oral lichen p lan u s: observations on 722 p atien ts from India. J O ral P a th o l 15(2):71-77, 1986. 19. P ogrel, M.A., an d W eldon, L .L . C arcinom a a risin g in erosive lichen p la n u s in the m id lin e d o r sum of the tongue. O ral Surg 55(l):62-66, 1983. 20. Silverm an, S.; G orsky, M.; an d Lozada-N ur, F. A prospective follow -up study of 570 p atien ts w ith oral lichen p la n u s: persistence, rem ission, an d m a lig n a n t association. O ral S urg 60(l):30-34, 1985. 21. Kovesi, G ., an d Banoczy, J. Fo llo w -u p studies
in oral lichen planus. In t J O ral S u rg 2(1): 13-19, 1973. 22. Y esudian, P., an d R aghuveera, R. M alig n an t tran sfo rm atio n of hy p ertro p h ic lichen planus. In t J D erm atol 24(3): 177-178, 1985. 23. Vas’kovskaia, G .P ., and others. D evelopm ent of cancer in lichen p la n u s foci of the o ral an d verm ilion b o rd er m ucosa. S tom ato lo g iia (M osk) 60(3):46-48, 1981. 24. H o lm stru p , P., and Pindborg, J. E rythroplakic lesions in re la tio n to oral lichen p la n u s. Acta Derm Venereol (S uppl) (Stockh) 59(25):77-84, 1979. 25. Shklar, G . L ichen plan u s as a n oral ulcerative disease. O ral S urg 33(3):376-388, 1972. 26. C aw son, R.A. T re a tm e n t of oral lichen p la n u s w ith betam ethasone. Br Med J l(5584):86-89, 1968. 27. V on A bram ova, E.J. L ichen ru b er p la n u s der m u n d h o h le. D erm atol W ochenschr 154(14):315-323, 1968. 28. G rin sp a n , D., an d others. N otre experience sur le lichen ru b er p la n u s de la m u q u eu se buccale. Ann D erm atol Venereol 93(5-6):531-542, 1966. 29. A ltm an, J., and Perry, H .O . T h e variations and course of lichen planus. Arch D erm atol 84:179-191, 1961. 30. Sugar, I., an d Banoczy, J. U n tersuchungen bei prakanzerose der m undschleim haut. D tsch Zahn M und K eiferheilkd Zentralbl G esam te 30:132-140, 1959. 31. D echaum e, M.; Payen, J.; an d P irio u , J. Le lich en p la n isole de la m u q u eu se buccale: considera tions an ato m o clin iq u es d ’apres 50 observations d o n t 30 avec exam en h istologique. Presse M ed 65:21332135, 1957. 32. Scheurm an, H . Zur carcin o m en tsteh u n g au f lichen ruber. D erm atol W ochenschr 108:230, 1939. 33. M ontgom ery, D.S., and C ulver, G.D. L ichen
p lan u s of the m o u th alone. Br T D erm atol 41:45-50, 1929. 34. W illiger, F. L ichen ru b er p la n u s a n d karzinom . V jschr f Z ah n h 1:58-61, 1924. 35. K aplan, B., and Barnes, L. O ral lichen planus an d sq u am o u s carcinom a: case re p o rt a n d u pdate of the literature. A rch O tolaryngol lll(8):543-547, 1985. 36. M ashberg, A., an d Meyers, H . A natom ic site and size of 222 early asym ptom atic oral squam ous cell carcinom as. C ancer 37(5):2149-2157, 1976. 37. Frazell, E.L ., an d L ucas, J.C . C ancer of the tongue: re p o rt of the m an ag em en t of 1,554 patients. C ancer 15(6): 1085-1099,1962. 38. D aniels, T .E ., and Q uadra-W hite, C. Direct im m unofluorescence in oral m ucosal disease: a diag nostic analysis of 130 cases. O ral S u rg 51 (1 ):38-47, 1981. 39. Laskaris, G.; Slavounou, A.; and A ngelopoulos, A. D irect im m unofluorescence in lichen planus. O ral S urg 53(5):483-487, 1982. 40. O gus, H .D ., an d Bennett, M .H . C arcinom a of the dorsu m of the tongue: a rarity o r m isdiagnosis. Br J O ral S urg 16(2): 115-124, 1978. 41. D om onkos, A.N.; A rnold, H .L .; and O dom , R.B. A ndrew s’ diseases of the skin: clinical derm atol ogy, ed 7. P h ilad e lp h ia , W. B. Saunders Co, 1982, p p 1068-1069. 42. L indelof, B., a n d E k lu n d , G. Incidence of m a lig n a n t skin tum ors in 14,140 patien ts after grenzray treatm en t for b e n ig n skin disorders. Arch Der m atol 122( 12): 1391-1395, 1986. 43. W aldron, C.A., an d Shafer, W .G. L eukoplakia revisited. C ancer 36(4): 1386-1392, 1975. 44. Shafer, W .G ., a n d W aldron, C.A. Erythroplakia of the oral cavity. C ancer 36(3): 1021-1028, 1975.
Mandibular pain as the initial and sole clinical manifestation of coronary insufficiency: report of case Barbara J. B atcheider, D M D D avid J. K rutchkoff, D D S , M S Jea n A m ara, D M D
A case of anginal pain limited to the mandible with secondary radiation of the pain to the neck and clavicular regions is presented. Although the pain was initially diagnosed as odontogenic in origin, fur ther historical workup suggested the suspicion of referred pain from coronary insufficiency. Immediate cardiac evalua tion confirmed the nature of the pain as angina. Important aspects involved with differential diagnosis of referred anginal pain are also discussed.
710 ■ JADA, Vol. 115, N ovem ber 1987
ardiac p a in (angina) is the m ost im p o rta n t early clinical m anifes tation of life-threatening coronary artery disease. P ro m p t detection, identifi cation, and ap p ro p riate m anagem ent of ang in a are essential in averting otherwise catastrophic sequelae (for exam ple, acute m yocardial infarction). A lthough an g in a usually appears as pain in the chest or left arm , the possibility of an g in a found solely as pain in the head and neck region should not be overlooked. Coronary insuf ficiency m ust be considered in the differ ential diagnosis of oral o r facial pain,
C
particularly after the m ore com m on local causes have been carefully checked and deemed unlikely. Report of case A 71-year-old, ap p aren tly healthy w hite m ale was exam ined by his dentist in A ugust 1985; he h ad vague, interm ittent p ain in the m andible of 1 to 2 m o n th s’ duration. T h e p a in was described by the p atien t as a “sensation of pressure, like a bad to othache” th a t occurred prim arily after eating and som etim es d u rin g peri-
CLINICAL
ods of exertion, such as playing a game of tennis. T he patient was edentulous in the maxilla and had only three remaining teeth, the two contiguous left m andibular prem olars an d canine. All teeth had apparently adequate full coverage. The canine and the second p rem o lar had previously been endodontically treated leaving the first premolar as the only rem aining tooth w ithout previous end odontic therapy (Fig 1). The patient’s pain was initially diag nosed as odontogenic in origin and was thought to be secondary to pulpal disease of the first premolar. T he patient was referred to an endodontist who performed endodontic treatment on the rem aining untreated tooth and referred the patient to the general practitioner for completion of care. During the next examination, the general practitioner noted that, in spite of the recent endodontic procedure, the patient’s pain was still present and had not changed significantly since comple tion of therapy 1 week earlier. T he patient was then referred to the departm ent of oral diagnosis for diagnostic consultation. Further questioning during exam ina tion disclosed that the pain seemed to stem from the left side of the mandible and often radiated to the patient’s back, shoulder, or clavicular region. There was no pain in the chest or arm. T he pain seemed to last approximately 30 minutes and then apparently subsided with rest. It was also disclosed that the first episode of pain had occurred almost 1 to 2 m onths earlier, primarily as a feeling of pressure in the patient’s mandible. Subsequently, however, the pain became progressively more severe and seemed localized to the left side of the mandible. Because the epi sodes seemed to occur m ainly after meals,
F ig 1 ■ Periapical film o f the p a tien t’s three rem aining teeth (mandibular left canine, first and second premolars) at the time o f the in itia l exam ination. T he pain was thought to be caused by p u lp al disease of the untreated first premolar, and the patient was subsequently referred for endodontic treatment.
REPORTS
Fig 2 ■ Periapical film s of rem aining mandibular left teeth plu s adjacent posterior edentulous bone taken after com pletion of endodontic therapy and placem ent of post. In view of findings, local disease was considered as an unlikely explanation for the patient’s pain.
the patient attributed the pain to a prob lem with his m andibular partial denture. In itia lly , the p a in caused only m ild discomfort and the patient sought consul tation with his general dentist who had been treating him. T he dental history was otherwise noncontributory. The patient had gout and hypertension, the latter co ntrolled adequately w ith diuretics. T he patient also had a history of transitional carcinoma of the renal pelvis in January 1981; a transurethral prostatectomy was performed in December 1981. Tissue analysis from this procedure confirmed the diagnosis of grade II tran sitional cell carcinom a of the bladder. Results of subsequent cytoscopic exami nations after surgery were negative for recurrence of carcinoma. In October 1984, the patien t had unrelated left indirect inguinal herniorrhaphy. O ther than his current m edication of diazide (25 mg daily), the patient’s medical history was otherwise noncontributory. Physical examination showed a moder ately overweight yet athletic-appearing ad u lt w hite male. Blood pressure was 148/78 mm H g (left arm, sitting). The pulse was 68 and regular. Extra- and intraoral examinations were noncontrib utory aside from a m axillary complete denture and a mandibular partial denture. Only three teeth remained of the natural dentition, all of which had been end odontically treated and restored with full crowns. Mild gingival inflammation was noted around the remaining teeth with b leed in g on p ro b in g . Pocket depths ranged from 2 to 4 mm. All other oral tissues were w ithin normal limits. Two additional periapical radiographs were obtained and interpreted as essen tially unremarkable (Fig 2). After consid eration of historical, clinical, and radiographic data, it was determined that local
factors could not adequately account for the patient’s reported m andibular pain. Because of the suspicion of occult coro nary insufficiency, the patient’s physician was contacted and asked to see the patient as soon as possible. T h e p a tien t was advised of the urgency of the situation and saw his physician the next m orning. Shortly thereafter, the patient was ad m itted to the hospital and underwent thorough cardiac evaluation. T he electro cardiogram (ECG) showed severe anterior wall injury and ischemia when compared with a normal ECG taken 1 year ealier (October 1984). Coronary angiography disclosed 90% occlusion of the left ante rior descending coronary artery. T his cor responded with the area on the ECG that showed ischemic changes. W ith com pletion of the diagnostic phase, the patient was treated with nitro glycerin paste, 1 in every 6 hours. He also received nifedipine (10 mg three times a day), hydrochlorothiazide (one capsule daily), plus nitroglycerin tablets to be taken as needed. T he patient reported that the mandibular pain subsided immediately after appropriate nitroglycerin medication. Currently the patient is being followed by the cardiologist on an outpatient basis to determine the adequacy of his thera peutic regimen. There still remains the future option of a surgical bypass proce dure depending on the progression of symptoms with current medication. Discussion
Angina pain was first described as a m an ifestation of coronary disease in 1802.' Today, angina is readily recognized and diagnosed when appearing in the usual clinical manifestation as classic angina pectoris; that is, with constricting substernal pain radiating to the left arm or
Batchelder-Krutchkoff-Amara : MANDIBULAR PAIN AS CORONARY INSUFFICIENCY ■ 711
CLINICAL
REPORTS
neck.2 A ngina is usually brought on by physical exertion, em otional upset, or ingestion of food. Classically, anginal pain is promptly relieved by rest or by s u b lin g u a l ad m in istration of n itr o glycerin. Early descriptions of anginal heart pain did not include reference to the fact that it could occasionally be found as referred pain to the face and jaw. More recently, pain in the head and neck has been rec ognized as a possible sign of heart dis ease.2 When angina is present as referred pain to the head or neck, the typical pat tern resembles that of pain in the chest and arm, radiating upward to the neck and into the angle of the jaw. This classic presen tation offers little d ifficu lty in recognition, especially if the facial pain occurs during exertion or excitement and has the sam e q u a lity as the thoracic discomfort it accompanies. In contrast, substantial diagnostic difficulties arise when cardiac pain occurs in the absence of any symptoms in the chest or left arm. In fact, it is rare for angina to be found as jaw or facial discomfort without pain in the chest or arm. When anginal pain is lim ited to the face or jaw, its true nature as referred pain or coronary insufficiency m ay be co m p letely overlook ed . T h e unfortunate result of such an oversight is lack of recognition of underlying heart disease. A secondary and less important consequence is inappropriate local dental treatment for a condition that has no rela tionship to dental disease. Many reports in the medical literature indicate that pain of cardiac origin may be referred beyond the chest to the jaws and teeth .2'4"7 A typ ical case is that reported by Bell8 in which angina was seen as sim ultaneous pain in the left shoulder and left side of the mandible. However, sole manifestation of cardiacrelated pain outside of the chest is appar ently uncomm on. In an analysis of 150 patients w ith anginal symptoms, Samp son and C heitlin3 report that 96% had chest pain. In 34% of the total cases, chest pain was the only manifestation of angina. In approximately one third of the cases, the angina radiated to the left arm and wrist as well. In 10% of the cases, pain
712 ■ JADA, Vol. 115, November 1987
radiated to the right arm and in 13% to the right wrist. In 22% of the patients studied, angina pain radiated to the neck and in 9% to the mandible. In 16%, angina pain was recognized as radiating to the back. Sole involvement outside the chest was uncomm on and was mentioned in only five cases of the 150 studied. Of these five, two had angina present as pain only in the neck, two with pain only in the left wrist, and one with pain only in the epigastrium. None of the 150 patients studied had jaw pain alone. Others4 have reported that in 18% of all cases, cardiac pain is localized solely to the jaw and teeth. However, there are few well-documented reports in the dental literature.9"11 A notable exception is the recent case reported by Edge12 in which angina was seen solely as pain of the soft palate. D entists have an im portant role as diagnosticians, especially with regard to pain of the head and neck region. It is important to remember that there is no single formula for the correct diagnosis of any unknown clinical problem. Further, cases involving the diagnosis of unusual or vague facial pain can be am ong the most difficult of diagnostic problems.13 When encountering clinical problems that are not adequately explained by local causes, it is the responsibility of the den tist to m ake correct assessm ents and appropriate referrals if necessary. T he examiners must approach each patient w ith an open m ind. A thorough and accurate historical database is imperative. An adequate history is as important, if not more so, than the clinical and radiographic components of the exam ination in determining the correct diagnosis. In this case, the key factors were: pain appeared first in one location (the left side of the mandible) and then radiated to the back and to the clavicular area; pain was brought on by exertion or a meal and subsided w ithin a rest period of 30 m in utes. These facts, coupled with a lack of findings to support a local cause, sug gested that observed pain was suspicious of coronary insufficiency. Appropriate m edical referral confirmed diagnostic suspicions, and the patient is now well
with prescribed treatment.
Conclusions There is no substitute for correct diagno sis regardless of the nature of medical or dental practice involved. The need for careful and thorou gh h istory takin g cannot be overemphasized. Careful con sideration of such w ill often reveal valu able information that w ill aid in making accurate diagnoses and performing appro priate treatment. O nly after a correct diagnosis is established can proper treat ment be instituted and optim al patient care be carried out.
-------------------- JSOA --------------------Dr. Batchelder is captain, Dental Corps, US Air Force. Dr. Krutchkoff is professor, department of oral diagn osis/p ath ology, School of Dental Medicine, University of Connecticut, Farmington, CT 06032. Dr. Amara is in private practice, Wethersfield, CT. Address requests for reprints to Dr. Krutchkoff. 1. Gorlin, R. Patho-physiology of cardiac pain. Circulation 32:138-144,1965. 2. Paine, R. Vascular facial pain. In A ilin g, C.C. I ll, and Mahan, P., eds. Facial pain, ed 2. Philadel phia, Lea 8: Febiger, 1977. 3. Sampson, J.J., and Cheitlin, M.D. Pathophysi ology and differential diagnosis of cardiac pain. Prog Cardiovasc Dis 13(6):507-531,1971. 4. B onica, J.J. T h e m anagem ent o f p ain w ith special emphasis on the use of analgesic block in diagnosis, prognosis, and therapy. Philadelphia, Lea Sc Febiger, 1953, p 1318. 5. Rushmer, R.F. Cardiovascular dynamics, ed 2. Philadelphia, W. B. Saunders Co, 1961, p p 225-226. 6. Mitchell, D.F.; Standish, S.M.; and Fast, T.B. Oral diagnosis/oral medicine. Philadelphia, Lea 8c Febiger, 1971, p 224. 7. Dalessio, D.J. W olf’s headache and other pain, N ew York, Oxford University Press, 1972, pp 38, 617. 8. Bell, W.E. Orofacial pain—differential diagno sis. Dallas, Dedeco, 1973, pp 197-200. 9. Matson, M.S. Pain in orofacial region associated w ith coronary insufficiency. Oral Surg 16(3):284-285, 1963. 10. N atkin, E.; Harrington, G.W.; and Mandel, M.A. A nginal pain referred to the teeth. Oral Surg 40(5):678-680, 1975. 11. Graham, L.L., and Schinbeckler, G.A. Orofa cial pain of cardiac origin. JADA 104(l):47-48, 1982. 12. Edge, C.J. A ngina pectoris presenting as pain of the soft palate. Br Dent J 158:335-336, 1985. 13. Norman, J.E. de. Facial pain and vascular dis ease: some clinical observations. Br J Oral Surg 8:138144, 1970.