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Multifactorial Facial Pain—Differential Diagnosis: A Case Report
JADA CLINICAL
ROUNDS
Multifactorial facial pain—differential diagnosis: a case report William C. Donlon, DMD, MA; Herman Kaplan, MD, DDS; Bahram Javid, BDS, DMD; Michael Harness, MA; Peggy Shultz, R P T ; Howard Rome, PhD ; Ronald Hwang, DMD; Eugene Santucci, DDS
T
h e c o m p le x it y o f h e a d a n d n e c k
n e e d s in c lu d e d a n t id e p r e s s a n t m e d ic a
a s a c o m b in e d h e a d a c h e a n d
a n a to m y
t io n , c o u n s e lin g , o r a l o r t h o t ic s , b io f e e d
w it h
b a c k / m u s c l e r e e d u c a t io n , p h y s i c a l t h e r
n o t ic e a b le . S h e h a d n o c t u r n a l b r u x is m ,
and
p s y c h o g e n ic
c o n d it io n s c o m b in e
th e
q u a lit y
o v e r la y to f o r m
in
of
p a in
r e q u is i t e s
f o r th e m u l t i d i s c i p l i n a r y a p p r o a c h . 1 A t
apy,
o r t h o d o n t ic s ,
and
o r t h o g n a t h ic
s u rg e ry .
t h a t s h e d e s c r ib e s a s “ I t s o u n d s
lik e
c h e w i n g o n ic e c u b e s . ” S h e b e g a n w e a r i n g w h it e
a n i g h t g u a r d a m o n t h a g o . T h e p a t ie n t
v e r s it y o f th e P a c i f i c , a te a m c o m b in i n g
f e m a le w h o s e i n i t i a l p r o b l e m w a s “ b o t h
d e s c r ib e s th e h e a d a c h e s a s a “ t i g h t e n i n g
th e s e r v ic e s o f o r a l a n d m a x i l l o f a c i a l
s id e s o f m y fa c e h u r t a l l th e t im e . ” T h e
o f t h e m u s c le s o f m y t e m p l e s a n d t h e
s u r g e r y , p s y c h ia t r y , p s y c h o lo g y , p s y
p a in h a d b e e n p re s e n t fo r 6 m o n t h s b e fo re
s id e s
c h o m e t r ic s , k in e s i o lo g y , p r o s t h o d o n t ic s ,
s h e c a m e to th e c l i n i c , a n d p r i o r t r e a t m e n t
q u i v e r i n g o f m y l i p a n d c h i n m u s c le s . ”
th e F a c i a l P a i n
R e s e a r c h C e n te rs , U n i
The
to o th a c h e
th e d e n ta l c o m p o n e n t b e in g m o re
p a t ie n t is a 2 3 - y e a r - o ld
of
my
fa c e .
S o m e t im e s
I
have
and
in c lu d e d a n x io ly t ic m e d ic a t io n a n d a n
T h e p a t ie n t r e p o r t e d t h a t lo r a z e p a m ,
r a d i o l o g y m e e ts w e e k ly to d ia g n o s e a n d
o r a l n ig h t g u a r d . C u r r e n t m e d ic a t io n s
1 m g t w ic e a d a y , h a d b e e n p r e s c r ib e d b y a n in t e r n is t . S h e s ta te d th a t “ a lo t
p h y s ic a l
th e ra p y ,
o r t h o d o n t ic s ,
tre a t t h is p a t ie n t p o p u la t io n . A d j u n c t
a re
c a r e b y th e n e u r o l o g y a n d o t o la r y n g o l o g y
( T y l e n o l n o . 3, M c N e i l P h a r m a c e u t ic a l)
a c e t a m in o p h e n
w it h
c o d e in e ,
o f u n p le a s a n t t h in g s h a v e h a p p e n e d
d e p a r t m e n t s i s a l s o a v a i l a b le . M a n y o f
a n d lo r a z e p a m
m e i n th e la s t 2 y e a r s .” W h e n q u e s t io n e d
( A t iv a n , W y e t h
Labo
to
th e p a t ie n t s a t th e c e n t e r h a v e s i g n i f i c a n t
ra to ry ). S h e w a s re fe rre d b y a g e n e ra l
on
p s y c h o p a t h o lo g ic c o n d it io n s
d e n t is t f o r e v a l u a t i o n o f a c o m p le x p a i n
h a s h a d f i n a n c i a l d i f f i c u lt ie s . S h e s h a r e s
d is o r d e r .
a ro o m
in c lu d in g
d e p r e s s io n , h y s t e r ia , h y p o c h o n d r ia s is , s o m a to fo rm
d is o r d e r s , a n d b o r d e r lin e
p e r s o n a lit y
t r a it s . A ls o ,
in d u c e d p a i n
th e o r g a n ic -
m a y in f lu e n c e p s y c h i a t r i c
e v a l u a t i o n a n d p s y c h o m e t r ic t e s t in g . 2 The
f o llo w in g
c a s e is p r e s e n t e d i n
T h e c o n f e r e n c e d is c u s s io n b e g in s w i t h a r e v ie w th e
o f th e p a t ie n t ’s s y m p t o m s a n d
f in d in g s
of
th e
head
and
neck
a lo n g
w i t h h e r s is t e r b u t d o e s n o t g e t w it h
p re g n a n t
t ig h t n e s s a r e w o r s e o n a w a k e n in g
Her
A c c o r d i n g t o th e p a t ie n t , t h e p a i n a n d th a n
d u r i n g th e r e s t o f t h e d a y . I t is e x a c e r b a t e d
D r. Ja v id (o ra l a n d m a x illo fa c ia l surgery).
by
T h e p a t ie n t d e s c r ib e d th e o n s e t o f p a i n
e x p e r ie n c e s
T re a tm e n t
a b o r t io n .
Conference presentation
s o c ia l
s y m p to m s .
p a t ie n t b e c a m e
an
b u t n o t h e r fa th e r .
h a d o r g a n ic , p s y c h ia t r ic , a n d p s y c h o and
The
had
e x a m in a t io n .
th e c o m p le t e c l i n i c a l te a m . T h i s p a t ie n t s ig n s
h e r.
and
m o t h e r w a s in f o r m e d o f t h is c ir c u m s t a n c e
a
t y p ic a l c o n fe r e n c e d is c u s s io n i n v o lv in g
t h is m a t t e r , s h e s a id t h a t h e r f a m i l y
s tre s s
and
s o c ia l
a
s e n s a t io n
p re ssu re s. of
d ry n e ss
She of
JADA, Vol. 120, March 1990 ■ 315
TMDISORDERS
A multidisciplinary algology team was formed to facilitate the diagnosis and treatment of complex head and neck pain disorders. The standard patient evaluation includes a history and physical, surface electromyography, Minnesota Multi-phasic Personality Inventory (MM PI), brief psychiatric interview, dental/occlusal analysis, a postural/ musculoskeletal examination; and necessary diagnostic imaging. Clinicians meet in conference after each clinic session. Organic and psychiatric findings are compiled and a differential diagnosis is made. Treatment recommendations are outlined and a review of the evaluation and the therapeutic plan are forwarded to the referring doctor. A typical conference discussion is presented here.
CLINICAL
ROUNDS
th e m o u t h a n d l ip s . I a s k e d i f h e r j a w
m a s t i c a t o r y a n d c e r v i c a l m u s c le s w e r e
r e la t iv e s . H e r f a t h e r w a s d i s t r a u g h t w i t h
j o in t s c lic k e d . S h e a n s w e r e d t h a t th e y
w it h in n o r m a l lim it s . 3
r e c e n t f i n a n c i a l r e v e r s a ls . A l t h o u g h
sh e
has an
th e
o f y e a rs b u t sh e h a s ig n o r e d H e r ja w s
ache
b o th
t h i s s ig n .
d u r in g
re st a n d
f u n c t io n . A c t io n s s u c h as b it in g
in t o
a n a p p l e e x a c e r b a t e th e p a in . T h e p a t ie n t d o e s n o t r e c a ll a n y s p e c if ic in j u r y
to
th e h e a d o r n e c k .
P r e v io u s
T h e p a t ie n t r e p o r t e d a b r u x is m to m e . I b r ie f ly
h a b it
d e s c r ib e d b io f e e d b a c k
o ld e r
d id
p r o b l e m s , a n d h e r s is t e r “ a c t e d c h i l d
n o s is
i s h l y ” a n d w a s n o t h e lp f u l. A s sh e t o ld
and
is h y p e r a c t iv it y o f th e f r o n t a lis
t e m p o r a lis m u s c le s . T h i s c o n d i t i o n
m a n a g e m e n t t h e r a p y a n d b io f e e d b a c k
ago
fix e d o r t h o d o n t ic tr e a tm e n t f r o m
m u s c le r e e d u c a t io n .
p a t ie n t
r e s p o n s iv e
to
s tre s s
Ms. S h u ltz (p h y sic al th erap y ). T h e p a t ie n t
H g ; a n d p u ls e 6 5 /
h a s s e v e re f o r w a r d
a n t e r io r s h o u ld e r g ir d le
r o t a t io n . H e r
a c t iv e c e r v ic a l r a n g e o f m o t io n
n e c k s o f t t is s u e s is u n r e m a r k a b le . M a x
s t r ic t e d
i m u m m a n d ib u l a r a b d u c t io n is m e a s u r e d
4 in
at an
b ila t e r a lly .
fo rw a rd
f le x io n F o rw a rd
fro m
c a n c e r c o m p lic a t io n s .
s a id
sh e
had
been
to
The see
a
T h e d i a g n o s is a t t h is t im e is d y s t h y m ic d is o r d e r w it h g ia .4
1 = “ lif e
s u b o c c ip it a l p a in
w h ile
s id e b e n d i n g
te n d e r n e s s to p a l p a t i o n o f th e t e m p o r a lis ,
p a lp a t io n :
m a s s e te r, m e d ia l p t e r y g o id , a n d s te r
s t e r n o c le id o m a s t o id , t e m p o r a lis , a n d
p a r t ic u la r , th e m a s s e te r,
n o c le id o m a s t o id
c o n f ir m a t io n
h a r d ly
w o rth
liv in g ” a n d
10
th e p a t ie n t m a r k e d a 3; o n
th e B e c k D e p r e s s io n I n v e n t o r y (a m u l t i p l e c h o ic e
H e r m u s c le s w e r e d e c id e d ly te n d e r to
w r it t e n
i n c lu d e d : o n a v is u a l a n a l o g s c a le w h e r e = “ t e r r if ic , ”
in c r e a s e s
o r g a n ic a r t h r a lg ia / m y a l-
F u rth e r
fle x io n
in c r e a s e s m i d c e r v ic a l p a in . in
h e r e m o t io n s .
a n d s id e b e n d in g
I m o l a r r e l a t i o n s h i p e x is t s w i t h
a n t e r i o r a p e r t o g n a t h ia . T h e r e is b i la t e r a l
is re
a t c e r v ic a l v e r t e b r a e 2, 3, a n d
( n o r m a l = 4 0 to 5 0 m m ) . A n A n g l e ’ s C la s s 2 -m m
t h e d e a t h o f h i s m o t h e r w h o d ie d 2 y e a r s
h e ad p o stu re a n d
m i n , r e g u la r . T h e c o n d i t i o n o f h e a d a n d
i n t e r in c is a l d is t a n c e o f 3 3 m m
s u b s ta n c e a b u se . H e w a s s t r u g g lin g w it h
p s y c h o t h e r a p is t a f e w t im e s to d e a l w i t h
t o 1980. S h e s m o k e s o n e p a c k o f c ig a r e t t e s
p re ssu re 1 1 5 /7 0 m m
th e
H e r b o y f r i e n d h a d s o m e t r o u b le w i t h
p a t ie n t
seem ed
headaches. T h e
c a p a b le o f h a n d lin g
m e a b o u t t h is , s h e b e g a n to w e e p .
is c o n s is t e n t w i t h th e h is t o r y o f b r u x is m m u s c le c o n t r a c t i o n
n o t seem
m i n a t i o n . T h e p a t ie n t h a d c o n v e n t i o n a l
s h o w e d b lo o d
lik e
t r e a t m e n t f o r m u s c le c o n t r a c t i o n h e a d
m o la r s , c y s t o s c o p y , a n d p r e g n a n c y t e r
P h y s ic a l e x a m in a t io n
f e lt
a c h e a n d f a c ia l f i b r o m y a lg i a . M y d i a g
and
p e r d a y a n d d o e s n o t d r i n k a lc o h o l.
she
r e s p o n s ib le o n e i n th e f a m i ly . H e r m o t h e r
s u r g ic a l h i s t o r y i n c l u d e s r e m o v a l o f t h i r d
1976
s is t e r ,
te st
d e p r e s s iv e
fo r
s c o r in g
illn e s s ) ,
th e
sh e
le v e l
s c o re d
of
a
22,
i n d i c a t i n g a d e p r e s s e d sta te ; a n d i n
her
m e d ic a l h e a lt h q u e s t io n n a ir e , s h e c h e c k e d
le v a t o r s c a p u la e m u s c le s . P a s s iv e v e r t e b r a l
t ir e d n e s s , w e a k n e s s , lo s s o f a p p e t it e ,
d e c id e d te n d e r n e s s to la t e r a l a n d e n d a u r a l
m o v e m e n t w a s r e s t r ic t e d a n d
w e ig h t lo s s g r e a t e r t h a n
p a lp a t io n
p o s t e r o a n t e r io r ( P A )
m u s c le s , w i t h
o f b o th
e q u a lly
t e m p o r o m a n d ib u la r
t e n d e r to
p re ssu re a t C
2
to
10 l b , e a r l y
a w a k e n in g , n e r v o u s n e s s , a n d
jo in t s ( T M J ) . C e p h a lo m e t r ic r a d io g r a p h
C 5 c e n t r a lly o n
i c a n a ly s is c o n f i r m e d v e r t ic a l m a x i l l a r y
a n d l a t e r a l ly o n th e t r a n s v e r s e p ro c e s s e s .
U n d e r th e h e a d a n d n e c k in v e n t o r y ,
excess,
r e t r o d i s p la c e m e n t ,
S e g m e n ta l m o v e m e n t w a s te n d e r fro m
s h e r e s p o n d e d p o s i t iv e ly to e v e ry c a t e g o r y
m ic r o g e n ia , s e c o n d a ry a p e r t o g n a t h ia ,
C 6 to T 3 w i t h P A p r e s s u r e s o n th e s p in o u s
except
a n d l i p in c o m p e t e n c e .
p ro ce sse s. T h e
c h e c k e d s i n u s p r o b le m s , n a s a l c o n g e s t io n ,
m a n d ib u la r
I n s u m m a r y , m y f i n d i n g s are : l im i t e d
u a t io n
th e s p in o u s p ro c e s s e s
m o r n in g
p h y s ic a l th e r a p y e v a l
is c o n s is t e n t w it h
fo rw a rd head
s le e p d i f f i c u lt ie s .
e a ra ch e s
and
g la u c o m a .
She
p o s t n a s a l d r ip , fr e q u e n t s o re th r o a ts ,
r a n g e o f m a n d ib u la r m o t io n ; d if f u s e
p o s t u r e , b i l a t e r a l r e s t r ic t io n o f c e r v i c a l
m ig r a in e h e a d a c h e s, a n d o th e r h e a d a ch e s.
m u s c le p a l p a t i o n te n d e rn e s s ; i n t e r m it t e n t
r a n g e o f m o t i o n , a n d c e r v ic a l v e r t e b r a l
T h i s c o u l d b e a c c o u n t e d f o r b y a lle r g ie s b u t th e p a t ie n t n o t e d o n ly A
h a y fe v e r.
p h y s ic a l c o m p o n e n t w a s f o u n d i n a ll
her
p r o b le m s .
She
had
a
h is t o r y
of
s t o m a c h u lc e r s , h e a r t b u r n , f r e q u e n t t h ir s t ,
M thorough patient evaluation and a comprehensive treat ment regimen are required for optimum results with a minimum of medicolegal complications.
a n d u r in a t io n .
D ia b e t e s c o u ld
account
f o r s o m e o f th e s e c o m p la in t s ; h o w e v e r , r e s u lt s o f a r e c e n t m e d ic a l e x a m i n a t i o n w e r e n e g a t iv e . U n d e r t h e h e a r t p r o b le m s c a t e g o r y , th e p a t ie n t c h e c k e d p a l p a t i o n s
n o n p a in f u l T M J
c lic k s ; b r u x is m ; a n d
a r t h r a lg ia . T h i s
p a t ie n t w o u ld
b e n e f it
a n d a n x ie t y .
c e p h a l o m e t r i c a l l y c o n f ir m e d “ l o n g fa c e ”
f r o m in t e n s iv e p h y s i c a l t h e r a p y to r e d u c e
sy n d ro m e . T h e
s o ft t is s u e a n d j o i n t r e s t r ic t io n s a n d
and
im p r o v e d y n a m ic a n d s t a t ic p o s t u r e .
a b d o m in a l p r o b le m s . T h e s e a re a s a ls o
( t h a t is , v e r t ic a l
D r. K a p la n ( p s y c h ia tr y ) . T h e p a t i e n t
p r o b a b l y r e la t e d to d e p r e s s io n .
m a x illa r y e x cess, m a n d ib u la r r e tr o g n a th -
is a 2 3 - y e a r - o ld w h it e w o m a n w h o l o o k s
is m , a p e r t o g n a t h ia , l a b i a l in c o m p e t e n c e ,
s o m e w h a t o ld e r t h a n h e r s ta te d a g e . H e r
w it h
a n d m e n t a lis
fa c e w a s l o n g a n d h e r e x p r e s s io n , w h i c h
d e p r e s s io n ) , n e u r o t i c a n x ie t y , a n d s o m a
s u r g ic a l e v a lu a t io n
is
c o n s is t e n t w i t h m a s t ic a t o r y f i b r o m y a lg i a , w h ic h
d e f o r m it y
m e n d a t io n s
s t r a in ) . S u r g ic a l r e c o m in c lu d e
c o r r e c t io n
s k e le t a l m a lo c c lu s io n
o f th e
a fte r tre a tm e n t
o f th e p a t ie n t ’ s p a in .
an
u n d e r ly in g
a n x ie t y
P s y c h ia t r ic e v a lu a t io n d y s t h y m ic
s ta te ,
is c o n s is t e n t
d is o r d e r
(e x o g e n o u s
to fo rm
h e r a t t e m p t to k e e p h e r l ip s
to g e th e r
o r g a n i c s y m p t o m s c a u s e d b y p s y c h o g e n ic
( lo n g fa c e s y n d r o m e ) . H e r f a m i l y b a c k
f a c t o r s s u c h as d e p r e s s io n . W i t h o u t r e g a r d
w a s u n r e m a r k a b le u n t il re c e n t
D r. H a rn e s s (e le c tro m y o g ra p h y , b e h a v io r a l m e d ic in e ). S u r f a c e E M G s h o w e d
f i n a n c i a l d i f f i c u l t i e s a ro se .
e le v a t e d e l e c t r i c a l le v e ls i n
u p p e r lip
f r o n t a l is a n d t e m p o r a li s a re a s . T h e o t h e r
upper
w a s sh y a n d sad , w a s a c c e n tu a te d b y
g ro u n d
th e r ig h t
in c lu d e d
lo w e r b a c k , s h o u ld e r s , n e c k , a n d
in d ic a t e
m a y b e s e c o n d a ry to th e m a x
illo f a c ia l
H e r h is t o r y o f p a in
S h e t a lk e d o f b i la t e r a l T M J p a i n a n d p a i n . S h e d e s c r ib e d a c h a o t ic
l if e s i t u a t i o n w i t h r e c e n t d e a th s o f c lo s e
to
( c o n v e r s i o n ) d i s o r d e r , t h a t is ,
th e p a t ie n t ’s o r g a n ic a s s e s s m e n t, 1
w o u ld
re co m m e n d
p s y c h o th e ra p y a n d
a n t id e p r e s s a n t m e d ic a t io n S p e c if ic a lly , t r ic y c lic
as needed.
com pounds
a re
m o s t a p p r o p r ia t e as th e y c a n a lle v ia t e
D onlon-Others : M ULTIFACTORIAL FACIAL PAIN DIAGNOSIS ■ 317
Tl¥l DISORDERS
h a v e in d e e d m a d e s o u n d s f o r a n u m b e r
CLINICAL
ROUNDS
t h e d e p r e s s io n a n d th e y a ls o h a v e a p a i n m o d u la t in g
f u n c t io n
b e c a u s e o f t h e ir
MALOCCLUSION -
s t i m u l a t i o n o f b i o g e n i c a m i n e s e c r e t io n
(open bite)
a t p a i n i n h i b i t o r n e r v e s y n a p s e s . P a t ie n t s g e n e r a lly
t o le r a t e b e s t t h e m e d i c a t i o n s
t h a t c a u s e th e le a s t s e d a t io n . I n
t h is
P O S T U R A L• DEFECTS
r e g a r d , c o u n s e l in g s h o u ld b e c o m b in e d w it h
d e s ip r a m in e
h y d r o c h lo r id e
USP
FACIAL DYSMORPHOLOGY
( N o r p r a m i n , M e r r i l l D o w ) o r tr a z o d o n e H C L
( D e s y r e l,
M e a d -Jo h n so n )
fo r
w it h
th e
tre a tm e n t o f
----------- ►FACIES
(long tace; tight, drawn lips)
(vertical maxillary excess)
o p t i m a l r e s u lt s . T h i s c a n b e d o n e s i m u l t a n e o u s ly
PAIN
-
th e
Fig 1 ■ Interrelationship of organic and psychiatric signs an d sym ptom s for subject.
o r g a n i c p a i n in d u c e r s .
M USCLE HYPERACTIVITY
D r. R o m e (c lin ic a l p sy c h o lo g y , p sy c h o m etrics). T h i s p a t ie n t p r o d u c e s a v a l i d
DEPRESSION
M M P I p r o f ile . T h e v a l i d i t y s c a le s in d ic a t e
(acute dysthymic disorder)
--------------
—
PAIN
► (bruxism)
t h a t s h e r e s p o n d e d to th e it e m s i n a c a n d id m a n n e r , w it h
n o a p p a r e n t a t t e m p t to
e it h e r m i n i m i z e o r e x a g g e r a t e h e r r e p o r t o f s y m p t o m s . T h e p a t t e r n s u g g e s ts t h a t sh e h a s a c o n s id e r a b le d e g r e e o f e m o t io n a l a b ilit y
to c o p e e f f e c t iv e ly w it h
s tre s s
i s lim it e d . o f s a d n e s s , g u i l t , a n d f a ilu r e . S e l f - c r i t i c a l
u a t io n
w h o d is p la y s m u l t i p l e c l i n i c a l s y m p t o m s
f e e lin g s
s e c o n d a r y to s k e le t a l f a c ia l d y s m o r p h o l -
o f n e r v o u s n e s s , d e p r e s s io n , a n d a n x ie t y .
t h o u g h t s o f s u ic id e b u t w i t h o u t i n t e n t i o n
o g y ; p o s t u r a l a b n o r m a lit ie s ; E M G
S o m a t ic c o r r e la t e s o f a n x i e t y a r e l ik e ly .
t o a c t o n t h e m . S h e r e p o r t s s le e p a n d
v a t io n s ;
D e p r e s s io n is u s u a l l y
a p p e t i t e d is t u r b a n c e s , a c c o m p a n ie d b y
m o t io n ; p a lp a t io n
w o r r y a b o u t p h y s i c a l p r o b le m s .
m a s t i c a t o r y a n d c e r v i c a l m u s c le s ; a n d
T h i s p a t ie n t ’s p r o f i l e i s t y p i c a l o f o n e
see n in
p e r v a s iv e
l a c k o f s e lf-e s te e m , d e s p o n d e n c y , f e e lin g s
a re
p re s e n t.
She
a d m it s
to
sh ow s: an
d e c id e d
lim it e d
a n t e r io r o p e n
te n d e rn e ss o f m a n y
p a lp a t io n
te n d e rn e s s
so m e
I n th e a b s e n c e o f a p p r o p r i a t e p s y c h i a t r i c i n t e r v e n t i o n , r e s p o n s e to c o n v e n
t e m p o r o m a n d ib u la r j o i n t s . T h e
s y m p t o m s s u c h as s le e p a n d a p p e t it e
t i o n a l d e n t a l o r s u r g ic a l t r e a t m e n t is
a t r ic w o r k - u p
d is t u r b a n c e s m a y b e p a r t o f th e c l i n i c a l
l i k e l y to b e c o m p lic a t e d b y p s y c h o lo g i c a l
c h o s o c ia l
p ic t u r e .
d if f ic u lt ie s .
s o m a t iz a t io n te n d e n c ie s .
T hese
in d iv id u a ls
a re
o fte n
d e s c r ib e d a s c h r o n i c w o r r ie r s w i t h
p e r-
f e c t i o n i s t i c a n d o b s e s s iv e p e r s o n a l it y
F u r t h e r p s y c h ia t r ic e v a lu
e le
m a n d ib u la r r a n g e o f
in s t a n c e s , s u i c i d a l t h o u g h t s . V e g e t a t iv e
o f g u ilt a n d in a d e q u a c y , a n d , in
b it e
of
is c o n s is t e n t w it h
s tre s s o rs ,
th e
p s y c h i
d e p r e s s io n s ,
psy and
a t io n a n d t r e a t m e n t is r e c o m m e n d e d as D r . J a v id . T h e
o u t li n e d b y D r . K a p la n .
in c lu d e s
tr a it s .
lo n g
d if f e r e n t ia l d ia g n o s is fa c e s y n d r o m e
( t h a t is ,
v e r t ic a l m a x i l l a r y e x c e s s w i t h
s o m a t ic s y m p t o m s . C h r o n i c
D rs. H w a n g a n d S a n tu c c i ( o r th o ti c s , o c c lu s a l a n a ly s is ) . W e a g r e e w i t h t h e
s t r e s s - in d u c e d a u t o n o m i c a r o u s a l m a y
a s s e s s m e n t m a d e b y D r . J a v id . T h e r e
p e t e n c e , m e n t a lis
r e s u lt in
is d e f in it e ly
a p e r t o g n a t h ia ; m u s c le c o n t r a c t i o n h e a d
P s y c h o l o g ic a l d i f f i c u lt ie s c a n b e r e p r e s e n te d i n
g a s t r o in t e s t in a l d is t u r b a n c e s ,
m a s t ic a t o r y a n d c e r v ic a l
s e c o n d a ry
r e t r o g n a t h is m ) , m i c r o g e n i a , l a b i a l i n c o m m u s c le
s t r a in , a n d
a l l l i k e l i h o o d , r e la t e d
a c h e ; m a s t ic a t o r y a n d c e r v ic a l f i b r o m y a l
d e f o r m it ie s p r e v io u s ly d is
g ia ; b ila t e r a l t e m p o r o m a n d ib u la r c a p
s y m p t o m s o r p s y c h o g e n ic p a i n ( o r b o t h )
c u s s e d . D e n t a lly , th e re is a s ig n if ic a n t
s u lit is ; e x o g e n o u s d e p r e s s io n ; f o r w a r d
a lt h o u g h
s k e le t a lly b a s e d m a lo c c lu s io n
th a t ha s
h e a d p o s t u r e a n d l i m i t e d c e r v ic a l r a n g e
n o t b e e n c o rre c te d b y r o u t in e o r t h o d o n t ic
o f m o t i o n ; p s y c h o s o c i a l s t r e s s / a n x ie t y ;
tre a tm e n t. T h is
a n d b r u x i s m ( F i g 1).
h e a d a c h e , i n s o m n i a , x e r o s t o m ia , a m o n g
f ib r o m y a lg ia , i n
o th e r s y m p to m s .
to th e j a w
E v id e n t c o n v e r s io n
s o m e w h a t le s s p r e v a l e n t a r e
s t i l l se e n i n p r o d u c in g
t h is p r o f i l e ty p e . I f a p a i n le s io n
is p r e s e n t , th e p a in
t o le r a n c e is l i k e l y to b e lo w e r e d s e c o n d a r y to d e p r e s s io n . M y i m p r e s s i o n
fro m
a d d r e s s e d f o r lo n g - t e r m s t a b iliz a t io n . I t is a d v i s a b le t o a d d r e s s t h e m u s c le
th e
p s y c h o m e t r ic p r o f i l e is a n a c u t e d e p r e s
p o in t m a y n e e d to b e
d is o r d e r f ir s t . A l o n g
w it h
Summary and conclusion
b io f e e d b a c k /
s i o n / a n x ie t y s y n d r o m e . T h e r e is a h i g h
stre s s m a n a g e m e n t a n d p h y s i c a l th e r a p y ,
The
p r o b a b ilit y
w e w o u ld
p ro to c o l
th a t th e o r ig in a l p h y s ic a l
in s t it u t e o r t h o t ic c a re w it h
te a m
re c o m m e n d e d th a t
in c lu d e d
a
tre a tm e n t
o ra l
m u s c le -
c o m p la in t s h a v e a s u b s t a n t ia l d e g re e
a f l a t p la n e ( m u s c le n e u t r a l iz i n g ) s p l in t .
n e u t r a liz in g s p lin t ; b io f e e d b a c k / m u s c le
o f p s y c h o l o g i c a l o v e r la y . I f a n o r g a n i c
The
r e e d u c a t io n / s t r e s s m a n a g e m e n t ; p h y s i c a l
p a t h o lo g ic c o n d it io n
m u s c le r e la x a n t w o u ld c o m p le m e n t s p l i n t
t h e r a p y ; p s y c h o lo g i c a l c o u n s e lin g ; a n t i
u se.
d e p r e s s a n t m e d ic a t io n ; n o n s t e r o id a l a n t i
D r. D o n lo n ( d i r e c t o r , F a c ia l P a in R esearch C en ter). T h i s i s a p a t ie n t w i t h
a n t m e d ic a t io n ; p r e s u r g i c a l o r t h o d o n t ic s ;
t o le r a n c e
is
lik e ly
is p r e s e n t , p a in
to
b e lo w .
I lln e s s
use o f a n N S A I D
a n a lg e s ic a n d a
i n f la m m a t o r y m e d ic a t io n ; m u s c le r e l a x
b e h a v io r w i l l t e n d to b e a b n o r m a l. I
a ls o n o t e t h a t o n th e B e c k D e p r e s s io n
In v e n to ry ,
th e
p a t ie n t
s c o re d
in
th e
m o d e r a t e t o s e v e r e ly d e p r e s s e d r a n g e .
a
u n iq u e
T h e d e p r e s s io n is c h a r a c t e r iz e d b y f e e lin g s
p s y c h ia t r ic
in t e r p la y
of
c o n d it io n s .
o r g a n ic P h y s ic a l
a n d o r t h o g n a t h ic m a x i l l o f a c i a l s u r g e r y . A
and e v a l-
a
c a s e r e p o r t w a s u s e d to illu s t r a t e
m u lt id is c ip lin a r y
a p p ro a ch
to
th e
Donlon-O thers : M ULTIFACTORIAL FACIAL PAIN DIAGNOSIS ■ 319
TIMI D I S O R D E R S
d is tr e s s a t th e p r e s e n t t im e a n d t h a t h e r
CLINICAL
ROUNDS
d i a g n o s is a n d
t r e a t m e n t o f f a c ia l p a in .
O f s ig n if ic a n c e
w a s t h e c o e x is t e n c e o f
is
a d v is a b le . A t h o r o u g h p a t ie n t e v a lu a t io n
o r g a n i c a n d p s y c h i a t r i c p a t h o lo g i c c o n
a n d a c o m p r e h e n s iv e t r e a t m e n t r e g im e n
d it io n s
in
a r e r e q u ir e d f o r o p t i m u m
la t e d ,
th e
t h is p a t ie n t . A l t h o u g h tw o
a s p e c ts
m e rg e d
u n re in
th e
a m in im u m
a y m p t o m o lo g y . S u c c e s s f u l tr e a tm e n t is
tio n s . T h e r e c o g n iz e
n a t u r e o f th e p a t ie n t ’ s illn e s s .
m a x i l l o f a c i a l a lg o lo g y .
o ra l an d
r e c o g n iz in g d e f o r m it y ,
and
t r e a t in g
m ig h t
th e s o m a t iz a t io n
not
th e s k e le t a l
have
a id e d
th a t w a s ca u se d b y
t e n d e n c ie s . A
r e c o g n iz in g
in
th e
p s y c h i
s y m p to m s
of
d e p r e s s io n a n d h e r “ l o n g , s h y , a n d s a d ” p h y s i o g n o m y m i g h t s u c c e s s f u lly a d d r e s s h e r m e n ta l s ta tu s w it h o u t a lle v ia t in g th e p a i n
c a u s e d b y h e r m u s c u lo s k e le t a l
s ta tu s . A
d e n t is t c o r r e c t i n g th e p a t ie n t ’s
b it e
m ig h t
o v e r lo o k
s k e le t a l d e f o r m it y s y m p t o m o lo g y s p e c ia lt y
th e
and
u n d e r ly in g
th e c o n v e r s io n
w i t h o u t th e b e n e f it o f
o f m u lt id is c ip lin a r y
c o n s u l
t a t io n . F o r c o m p li c a t e d p a i n d is o r d e r s o f th e h e a d a n d n e c k , th e m u lt i s p e c i a l t y a p p ro a ch
is
w e ll- t r a in e d c l i n i c i a n
m ust
th e m u lt if a c t o r ia l n a tu r e o f
m a x illo f a c ia l s u rg e o n ,
a b a te m e n t o f p a in a t r is t
r e s u lt s w i t h
o f m e d ic o le g a l c o m p li c a
b a s e d o n r e c o g n i t i o n o f th e m u l t i f a c t o r i a l An
DISORDERS
o r g a n ic a n d p s y c h ia t r ic c lin ic ia n s
e s s e n t ia l. 5
A
te a m
b a la n c e
320 ■ JADA, Vol. 120, March 1990
of
--------------------------- J'A D )A \ ---------------------------
T h e authors thank Dr. M arianne P. T ru ta for editorial review and Ms. Ann Pearce and Ms. Lori Bodhaine for their manuscript assistance. Dr. Donlon is director, the Facial Pain Research Center, University of the Pacific, 2155 Webster St, San Francisco 94115. He is clinical associate professor, Diagnostic Sciences, University of the Pacific, and m aintains a private practice. Dr. Kaplan is attending psychiatrist, Facial P ain Research Center; clinical professor, diag n o stic sciences, U niversity of the Pacific; and in private practice, care of the health professional. Dr. Javid is attending surgeon, Facial Pain Research Center and associate professor, oral and maxillofacial surgery, University of the Pacific. Dr. Harness is attending behavioral therapist, Facial Pain Research Center, and clinical assistant professor of diagnostic sciences, U niversity of the Pacific. He is a clinical psychologist whose private practice is limited to head and neck pain and post-traumatic
stress disorders. Ms. Shultz is a registered physical therapist and consultant, Facial Pain Research Center, whose private practice emphasizes care of head and n e c k /T M J patients. Dr. R om e is atte n d in g psy chologist, Facial Pain Research Center, on the staff, Psychiatry Liaison, at Pacific Presbyterian Medical Center, whose private practice focuses on psycho metric evaluation of pain. Dr. Hwang is attending d e n tist, F acial P ain R esearch C enter; c lin ic a l in stru cto r, diagnostic sciences, U niversity of the Pacific; and m aintains a private practice in general dentistry. Dr. Santucci is attending dentist, Facial Pain Research Center; clinical instructor, diagnostic sciences, University of the Pacific, and has a private practice in general dentistry. Address requests for reprints to Dr. Donlon. 1. Donlon WC, Jacobson AL. Maxillofacial pain. Am Fam Physician 1984;30:151-63. 2. Eversole LR, Stone CE, Matheson D, Kaplan H. Psychometric profiles and facial pain. Oral Surg Oral Med Oral Pathol 1985;60:269-74. 3. H arness MC, Eversole LR, D o n lo n WC. Comparison of clinical characteristics in myogenic, T M J internal derangement and atypical facial pain patients. Clin J Pain (In press). 4. Eversole LR, Machado L. Tem porom andibular jo in t internal derangem ents an d associated n e u romuscular disorders. JADA 1985;110:69-79. 5. Strain JJ, Hamerman D. Ombudsman (medicalpsychiatric) rounds. An approach to meeting patientstaff needs. Ann Intern Med 1978;88:550-5.
ROUNDS
Multifactorial facial pain—differential diagnosis: a case report William C. Donlon, DMD, MA; Herman Kaplan, MD, DDS; Bahram Javid, BDS, DMD; Michael Harness, MA; Peggy Shultz, R P T ; Howard Rome, PhD ; Ronald Hwang, DMD; Eugene Santucci, DDS
T
h e c o m p le x it y o f h e a d a n d n e c k
n e e d s in c lu d e d a n t id e p r e s s a n t m e d ic a
a s a c o m b in e d h e a d a c h e a n d
a n a to m y
t io n , c o u n s e lin g , o r a l o r t h o t ic s , b io f e e d
w it h
b a c k / m u s c l e r e e d u c a t io n , p h y s i c a l t h e r
n o t ic e a b le . S h e h a d n o c t u r n a l b r u x is m ,
and
p s y c h o g e n ic
c o n d it io n s c o m b in e
th e
q u a lit y
o v e r la y to f o r m
in
of
p a in
r e q u is i t e s
f o r th e m u l t i d i s c i p l i n a r y a p p r o a c h . 1 A t
apy,
o r t h o d o n t ic s ,
and
o r t h o g n a t h ic
s u rg e ry .
t h a t s h e d e s c r ib e s a s “ I t s o u n d s
lik e
c h e w i n g o n ic e c u b e s . ” S h e b e g a n w e a r i n g w h it e
a n i g h t g u a r d a m o n t h a g o . T h e p a t ie n t
v e r s it y o f th e P a c i f i c , a te a m c o m b in i n g
f e m a le w h o s e i n i t i a l p r o b l e m w a s “ b o t h
d e s c r ib e s th e h e a d a c h e s a s a “ t i g h t e n i n g
th e s e r v ic e s o f o r a l a n d m a x i l l o f a c i a l
s id e s o f m y fa c e h u r t a l l th e t im e . ” T h e
o f t h e m u s c le s o f m y t e m p l e s a n d t h e
s u r g e r y , p s y c h ia t r y , p s y c h o lo g y , p s y
p a in h a d b e e n p re s e n t fo r 6 m o n t h s b e fo re
s id e s
c h o m e t r ic s , k in e s i o lo g y , p r o s t h o d o n t ic s ,
s h e c a m e to th e c l i n i c , a n d p r i o r t r e a t m e n t
q u i v e r i n g o f m y l i p a n d c h i n m u s c le s . ”
th e F a c i a l P a i n
R e s e a r c h C e n te rs , U n i
The
to o th a c h e
th e d e n ta l c o m p o n e n t b e in g m o re
p a t ie n t is a 2 3 - y e a r - o ld
of
my
fa c e .
S o m e t im e s
I
have
and
in c lu d e d a n x io ly t ic m e d ic a t io n a n d a n
T h e p a t ie n t r e p o r t e d t h a t lo r a z e p a m ,
r a d i o l o g y m e e ts w e e k ly to d ia g n o s e a n d
o r a l n ig h t g u a r d . C u r r e n t m e d ic a t io n s
1 m g t w ic e a d a y , h a d b e e n p r e s c r ib e d b y a n in t e r n is t . S h e s ta te d th a t “ a lo t
p h y s ic a l
th e ra p y ,
o r t h o d o n t ic s ,
tre a t t h is p a t ie n t p o p u la t io n . A d j u n c t
a re
c a r e b y th e n e u r o l o g y a n d o t o la r y n g o l o g y
( T y l e n o l n o . 3, M c N e i l P h a r m a c e u t ic a l)
a c e t a m in o p h e n
w it h
c o d e in e ,
o f u n p le a s a n t t h in g s h a v e h a p p e n e d
d e p a r t m e n t s i s a l s o a v a i l a b le . M a n y o f
a n d lo r a z e p a m
m e i n th e la s t 2 y e a r s .” W h e n q u e s t io n e d
( A t iv a n , W y e t h
Labo
to
th e p a t ie n t s a t th e c e n t e r h a v e s i g n i f i c a n t
ra to ry ). S h e w a s re fe rre d b y a g e n e ra l
on
p s y c h o p a t h o lo g ic c o n d it io n s
d e n t is t f o r e v a l u a t i o n o f a c o m p le x p a i n
h a s h a d f i n a n c i a l d i f f i c u lt ie s . S h e s h a r e s
d is o r d e r .
a ro o m
in c lu d in g
d e p r e s s io n , h y s t e r ia , h y p o c h o n d r ia s is , s o m a to fo rm
d is o r d e r s , a n d b o r d e r lin e
p e r s o n a lit y
t r a it s . A ls o ,
in d u c e d p a i n
th e o r g a n ic -
m a y in f lu e n c e p s y c h i a t r i c
e v a l u a t i o n a n d p s y c h o m e t r ic t e s t in g . 2 The
f o llo w in g
c a s e is p r e s e n t e d i n
T h e c o n f e r e n c e d is c u s s io n b e g in s w i t h a r e v ie w th e
o f th e p a t ie n t ’s s y m p t o m s a n d
f in d in g s
of
th e
head
and
neck
a lo n g
w i t h h e r s is t e r b u t d o e s n o t g e t w it h
p re g n a n t
t ig h t n e s s a r e w o r s e o n a w a k e n in g
Her
A c c o r d i n g t o th e p a t ie n t , t h e p a i n a n d th a n
d u r i n g th e r e s t o f t h e d a y . I t is e x a c e r b a t e d
D r. Ja v id (o ra l a n d m a x illo fa c ia l surgery).
by
T h e p a t ie n t d e s c r ib e d th e o n s e t o f p a i n
e x p e r ie n c e s
T re a tm e n t
a b o r t io n .
Conference presentation
s o c ia l
s y m p to m s .
p a t ie n t b e c a m e
an
b u t n o t h e r fa th e r .
h a d o r g a n ic , p s y c h ia t r ic , a n d p s y c h o and
The
had
e x a m in a t io n .
th e c o m p le t e c l i n i c a l te a m . T h i s p a t ie n t s ig n s
h e r.
and
m o t h e r w a s in f o r m e d o f t h is c ir c u m s t a n c e
a
t y p ic a l c o n fe r e n c e d is c u s s io n i n v o lv in g
t h is m a t t e r , s h e s a id t h a t h e r f a m i l y
s tre s s
and
s o c ia l
a
s e n s a t io n
p re ssu re s. of
d ry n e ss
She of
JADA, Vol. 120, March 1990 ■ 315
TMDISORDERS
A multidisciplinary algology team was formed to facilitate the diagnosis and treatment of complex head and neck pain disorders. The standard patient evaluation includes a history and physical, surface electromyography, Minnesota Multi-phasic Personality Inventory (MM PI), brief psychiatric interview, dental/occlusal analysis, a postural/ musculoskeletal examination; and necessary diagnostic imaging. Clinicians meet in conference after each clinic session. Organic and psychiatric findings are compiled and a differential diagnosis is made. Treatment recommendations are outlined and a review of the evaluation and the therapeutic plan are forwarded to the referring doctor. A typical conference discussion is presented here.
CLINICAL
ROUNDS
th e m o u t h a n d l ip s . I a s k e d i f h e r j a w
m a s t i c a t o r y a n d c e r v i c a l m u s c le s w e r e
r e la t iv e s . H e r f a t h e r w a s d i s t r a u g h t w i t h
j o in t s c lic k e d . S h e a n s w e r e d t h a t th e y
w it h in n o r m a l lim it s . 3
r e c e n t f i n a n c i a l r e v e r s a ls . A l t h o u g h
sh e
has an
th e
o f y e a rs b u t sh e h a s ig n o r e d H e r ja w s
ache
b o th
t h i s s ig n .
d u r in g
re st a n d
f u n c t io n . A c t io n s s u c h as b it in g
in t o
a n a p p l e e x a c e r b a t e th e p a in . T h e p a t ie n t d o e s n o t r e c a ll a n y s p e c if ic in j u r y
to
th e h e a d o r n e c k .
P r e v io u s
T h e p a t ie n t r e p o r t e d a b r u x is m to m e . I b r ie f ly
h a b it
d e s c r ib e d b io f e e d b a c k
o ld e r
d id
p r o b l e m s , a n d h e r s is t e r “ a c t e d c h i l d
n o s is
i s h l y ” a n d w a s n o t h e lp f u l. A s sh e t o ld
and
is h y p e r a c t iv it y o f th e f r o n t a lis
t e m p o r a lis m u s c le s . T h i s c o n d i t i o n
m a n a g e m e n t t h e r a p y a n d b io f e e d b a c k
ago
fix e d o r t h o d o n t ic tr e a tm e n t f r o m
m u s c le r e e d u c a t io n .
p a t ie n t
r e s p o n s iv e
to
s tre s s
Ms. S h u ltz (p h y sic al th erap y ). T h e p a t ie n t
H g ; a n d p u ls e 6 5 /
h a s s e v e re f o r w a r d
a n t e r io r s h o u ld e r g ir d le
r o t a t io n . H e r
a c t iv e c e r v ic a l r a n g e o f m o t io n
n e c k s o f t t is s u e s is u n r e m a r k a b le . M a x
s t r ic t e d
i m u m m a n d ib u l a r a b d u c t io n is m e a s u r e d
4 in
at an
b ila t e r a lly .
fo rw a rd
f le x io n F o rw a rd
fro m
c a n c e r c o m p lic a t io n s .
s a id
sh e
had
been
to
The see
a
T h e d i a g n o s is a t t h is t im e is d y s t h y m ic d is o r d e r w it h g ia .4
1 = “ lif e
s u b o c c ip it a l p a in
w h ile
s id e b e n d i n g
te n d e r n e s s to p a l p a t i o n o f th e t e m p o r a lis ,
p a lp a t io n :
m a s s e te r, m e d ia l p t e r y g o id , a n d s te r
s t e r n o c le id o m a s t o id , t e m p o r a lis , a n d
p a r t ic u la r , th e m a s s e te r,
n o c le id o m a s t o id
c o n f ir m a t io n
h a r d ly
w o rth
liv in g ” a n d
10
th e p a t ie n t m a r k e d a 3; o n
th e B e c k D e p r e s s io n I n v e n t o r y (a m u l t i p l e c h o ic e
H e r m u s c le s w e r e d e c id e d ly te n d e r to
w r it t e n
i n c lu d e d : o n a v is u a l a n a l o g s c a le w h e r e = “ t e r r if ic , ”
in c r e a s e s
o r g a n ic a r t h r a lg ia / m y a l-
F u rth e r
fle x io n
in c r e a s e s m i d c e r v ic a l p a in . in
h e r e m o t io n s .
a n d s id e b e n d in g
I m o l a r r e l a t i o n s h i p e x is t s w i t h
a n t e r i o r a p e r t o g n a t h ia . T h e r e is b i la t e r a l
is re
a t c e r v ic a l v e r t e b r a e 2, 3, a n d
( n o r m a l = 4 0 to 5 0 m m ) . A n A n g l e ’ s C la s s 2 -m m
t h e d e a t h o f h i s m o t h e r w h o d ie d 2 y e a r s
h e ad p o stu re a n d
m i n , r e g u la r . T h e c o n d i t i o n o f h e a d a n d
i n t e r in c is a l d is t a n c e o f 3 3 m m
s u b s ta n c e a b u se . H e w a s s t r u g g lin g w it h
p s y c h o t h e r a p is t a f e w t im e s to d e a l w i t h
t o 1980. S h e s m o k e s o n e p a c k o f c ig a r e t t e s
p re ssu re 1 1 5 /7 0 m m
th e
H e r b o y f r i e n d h a d s o m e t r o u b le w i t h
p a t ie n t
seem ed
headaches. T h e
c a p a b le o f h a n d lin g
m e a b o u t t h is , s h e b e g a n to w e e p .
is c o n s is t e n t w i t h th e h is t o r y o f b r u x is m m u s c le c o n t r a c t i o n
n o t seem
m i n a t i o n . T h e p a t ie n t h a d c o n v e n t i o n a l
s h o w e d b lo o d
lik e
t r e a t m e n t f o r m u s c le c o n t r a c t i o n h e a d
m o la r s , c y s t o s c o p y , a n d p r e g n a n c y t e r
P h y s ic a l e x a m in a t io n
f e lt
a c h e a n d f a c ia l f i b r o m y a lg i a . M y d i a g
and
p e r d a y a n d d o e s n o t d r i n k a lc o h o l.
she
r e s p o n s ib le o n e i n th e f a m i ly . H e r m o t h e r
s u r g ic a l h i s t o r y i n c l u d e s r e m o v a l o f t h i r d
1976
s is t e r ,
te st
d e p r e s s iv e
fo r
s c o r in g
illn e s s ) ,
th e
sh e
le v e l
s c o re d
of
a
22,
i n d i c a t i n g a d e p r e s s e d sta te ; a n d i n
her
m e d ic a l h e a lt h q u e s t io n n a ir e , s h e c h e c k e d
le v a t o r s c a p u la e m u s c le s . P a s s iv e v e r t e b r a l
t ir e d n e s s , w e a k n e s s , lo s s o f a p p e t it e ,
d e c id e d te n d e r n e s s to la t e r a l a n d e n d a u r a l
m o v e m e n t w a s r e s t r ic t e d a n d
w e ig h t lo s s g r e a t e r t h a n
p a lp a t io n
p o s t e r o a n t e r io r ( P A )
m u s c le s , w i t h
o f b o th
e q u a lly
t e m p o r o m a n d ib u la r
t e n d e r to
p re ssu re a t C
2
to
10 l b , e a r l y
a w a k e n in g , n e r v o u s n e s s , a n d
jo in t s ( T M J ) . C e p h a lo m e t r ic r a d io g r a p h
C 5 c e n t r a lly o n
i c a n a ly s is c o n f i r m e d v e r t ic a l m a x i l l a r y
a n d l a t e r a l ly o n th e t r a n s v e r s e p ro c e s s e s .
U n d e r th e h e a d a n d n e c k in v e n t o r y ,
excess,
r e t r o d i s p la c e m e n t ,
S e g m e n ta l m o v e m e n t w a s te n d e r fro m
s h e r e s p o n d e d p o s i t iv e ly to e v e ry c a t e g o r y
m ic r o g e n ia , s e c o n d a ry a p e r t o g n a t h ia ,
C 6 to T 3 w i t h P A p r e s s u r e s o n th e s p in o u s
except
a n d l i p in c o m p e t e n c e .
p ro ce sse s. T h e
c h e c k e d s i n u s p r o b le m s , n a s a l c o n g e s t io n ,
m a n d ib u la r
I n s u m m a r y , m y f i n d i n g s are : l im i t e d
u a t io n
th e s p in o u s p ro c e s s e s
m o r n in g
p h y s ic a l th e r a p y e v a l
is c o n s is t e n t w it h
fo rw a rd head
s le e p d i f f i c u lt ie s .
e a ra ch e s
and
g la u c o m a .
She
p o s t n a s a l d r ip , fr e q u e n t s o re th r o a ts ,
r a n g e o f m a n d ib u la r m o t io n ; d if f u s e
p o s t u r e , b i l a t e r a l r e s t r ic t io n o f c e r v i c a l
m ig r a in e h e a d a c h e s, a n d o th e r h e a d a ch e s.
m u s c le p a l p a t i o n te n d e rn e s s ; i n t e r m it t e n t
r a n g e o f m o t i o n , a n d c e r v ic a l v e r t e b r a l
T h i s c o u l d b e a c c o u n t e d f o r b y a lle r g ie s b u t th e p a t ie n t n o t e d o n ly A
h a y fe v e r.
p h y s ic a l c o m p o n e n t w a s f o u n d i n a ll
her
p r o b le m s .
She
had
a
h is t o r y
of
s t o m a c h u lc e r s , h e a r t b u r n , f r e q u e n t t h ir s t ,
M thorough patient evaluation and a comprehensive treat ment regimen are required for optimum results with a minimum of medicolegal complications.
a n d u r in a t io n .
D ia b e t e s c o u ld
account
f o r s o m e o f th e s e c o m p la in t s ; h o w e v e r , r e s u lt s o f a r e c e n t m e d ic a l e x a m i n a t i o n w e r e n e g a t iv e . U n d e r t h e h e a r t p r o b le m s c a t e g o r y , th e p a t ie n t c h e c k e d p a l p a t i o n s
n o n p a in f u l T M J
c lic k s ; b r u x is m ; a n d
a r t h r a lg ia . T h i s
p a t ie n t w o u ld
b e n e f it
a n d a n x ie t y .
c e p h a l o m e t r i c a l l y c o n f ir m e d “ l o n g fa c e ”
f r o m in t e n s iv e p h y s i c a l t h e r a p y to r e d u c e
sy n d ro m e . T h e
s o ft t is s u e a n d j o i n t r e s t r ic t io n s a n d
and
im p r o v e d y n a m ic a n d s t a t ic p o s t u r e .
a b d o m in a l p r o b le m s . T h e s e a re a s a ls o
( t h a t is , v e r t ic a l
D r. K a p la n ( p s y c h ia tr y ) . T h e p a t i e n t
p r o b a b l y r e la t e d to d e p r e s s io n .
m a x illa r y e x cess, m a n d ib u la r r e tr o g n a th -
is a 2 3 - y e a r - o ld w h it e w o m a n w h o l o o k s
is m , a p e r t o g n a t h ia , l a b i a l in c o m p e t e n c e ,
s o m e w h a t o ld e r t h a n h e r s ta te d a g e . H e r
w it h
a n d m e n t a lis
fa c e w a s l o n g a n d h e r e x p r e s s io n , w h i c h
d e p r e s s io n ) , n e u r o t i c a n x ie t y , a n d s o m a
s u r g ic a l e v a lu a t io n
is
c o n s is t e n t w i t h m a s t ic a t o r y f i b r o m y a lg i a , w h ic h
d e f o r m it y
m e n d a t io n s
s t r a in ) . S u r g ic a l r e c o m in c lu d e
c o r r e c t io n
s k e le t a l m a lo c c lu s io n
o f th e
a fte r tre a tm e n t
o f th e p a t ie n t ’ s p a in .
an
u n d e r ly in g
a n x ie t y
P s y c h ia t r ic e v a lu a t io n d y s t h y m ic
s ta te ,
is c o n s is t e n t
d is o r d e r
(e x o g e n o u s
to fo rm
h e r a t t e m p t to k e e p h e r l ip s
to g e th e r
o r g a n i c s y m p t o m s c a u s e d b y p s y c h o g e n ic
( lo n g fa c e s y n d r o m e ) . H e r f a m i l y b a c k
f a c t o r s s u c h as d e p r e s s io n . W i t h o u t r e g a r d
w a s u n r e m a r k a b le u n t il re c e n t
D r. H a rn e s s (e le c tro m y o g ra p h y , b e h a v io r a l m e d ic in e ). S u r f a c e E M G s h o w e d
f i n a n c i a l d i f f i c u l t i e s a ro se .
e le v a t e d e l e c t r i c a l le v e ls i n
u p p e r lip
f r o n t a l is a n d t e m p o r a li s a re a s . T h e o t h e r
upper
w a s sh y a n d sad , w a s a c c e n tu a te d b y
g ro u n d
th e r ig h t
in c lu d e d
lo w e r b a c k , s h o u ld e r s , n e c k , a n d
in d ic a t e
m a y b e s e c o n d a ry to th e m a x
illo f a c ia l
H e r h is t o r y o f p a in
S h e t a lk e d o f b i la t e r a l T M J p a i n a n d p a i n . S h e d e s c r ib e d a c h a o t ic
l if e s i t u a t i o n w i t h r e c e n t d e a th s o f c lo s e
to
( c o n v e r s i o n ) d i s o r d e r , t h a t is ,
th e p a t ie n t ’s o r g a n ic a s s e s s m e n t, 1
w o u ld
re co m m e n d
p s y c h o th e ra p y a n d
a n t id e p r e s s a n t m e d ic a t io n S p e c if ic a lly , t r ic y c lic
as needed.
com pounds
a re
m o s t a p p r o p r ia t e as th e y c a n a lle v ia t e
D onlon-Others : M ULTIFACTORIAL FACIAL PAIN DIAGNOSIS ■ 317
Tl¥l DISORDERS
h a v e in d e e d m a d e s o u n d s f o r a n u m b e r
CLINICAL
ROUNDS
t h e d e p r e s s io n a n d th e y a ls o h a v e a p a i n m o d u la t in g
f u n c t io n
b e c a u s e o f t h e ir
MALOCCLUSION -
s t i m u l a t i o n o f b i o g e n i c a m i n e s e c r e t io n
(open bite)
a t p a i n i n h i b i t o r n e r v e s y n a p s e s . P a t ie n t s g e n e r a lly
t o le r a t e b e s t t h e m e d i c a t i o n s
t h a t c a u s e th e le a s t s e d a t io n . I n
t h is
P O S T U R A L• DEFECTS
r e g a r d , c o u n s e l in g s h o u ld b e c o m b in e d w it h
d e s ip r a m in e
h y d r o c h lo r id e
USP
FACIAL DYSMORPHOLOGY
( N o r p r a m i n , M e r r i l l D o w ) o r tr a z o d o n e H C L
( D e s y r e l,
M e a d -Jo h n so n )
fo r
w it h
th e
tre a tm e n t o f
----------- ►FACIES
(long tace; tight, drawn lips)
(vertical maxillary excess)
o p t i m a l r e s u lt s . T h i s c a n b e d o n e s i m u l t a n e o u s ly
PAIN
-
th e
Fig 1 ■ Interrelationship of organic and psychiatric signs an d sym ptom s for subject.
o r g a n i c p a i n in d u c e r s .
M USCLE HYPERACTIVITY
D r. R o m e (c lin ic a l p sy c h o lo g y , p sy c h o m etrics). T h i s p a t ie n t p r o d u c e s a v a l i d
DEPRESSION
M M P I p r o f ile . T h e v a l i d i t y s c a le s in d ic a t e
(acute dysthymic disorder)
--------------
—
PAIN
► (bruxism)
t h a t s h e r e s p o n d e d to th e it e m s i n a c a n d id m a n n e r , w it h
n o a p p a r e n t a t t e m p t to
e it h e r m i n i m i z e o r e x a g g e r a t e h e r r e p o r t o f s y m p t o m s . T h e p a t t e r n s u g g e s ts t h a t sh e h a s a c o n s id e r a b le d e g r e e o f e m o t io n a l a b ilit y
to c o p e e f f e c t iv e ly w it h
s tre s s
i s lim it e d . o f s a d n e s s , g u i l t , a n d f a ilu r e . S e l f - c r i t i c a l
u a t io n
w h o d is p la y s m u l t i p l e c l i n i c a l s y m p t o m s
f e e lin g s
s e c o n d a r y to s k e le t a l f a c ia l d y s m o r p h o l -
o f n e r v o u s n e s s , d e p r e s s io n , a n d a n x ie t y .
t h o u g h t s o f s u ic id e b u t w i t h o u t i n t e n t i o n
o g y ; p o s t u r a l a b n o r m a lit ie s ; E M G
S o m a t ic c o r r e la t e s o f a n x i e t y a r e l ik e ly .
t o a c t o n t h e m . S h e r e p o r t s s le e p a n d
v a t io n s ;
D e p r e s s io n is u s u a l l y
a p p e t i t e d is t u r b a n c e s , a c c o m p a n ie d b y
m o t io n ; p a lp a t io n
w o r r y a b o u t p h y s i c a l p r o b le m s .
m a s t i c a t o r y a n d c e r v i c a l m u s c le s ; a n d
T h i s p a t ie n t ’s p r o f i l e i s t y p i c a l o f o n e
see n in
p e r v a s iv e
l a c k o f s e lf-e s te e m , d e s p o n d e n c y , f e e lin g s
a re
p re s e n t.
She
a d m it s
to
sh ow s: an
d e c id e d
lim it e d
a n t e r io r o p e n
te n d e rn e ss o f m a n y
p a lp a t io n
te n d e rn e s s
so m e
I n th e a b s e n c e o f a p p r o p r i a t e p s y c h i a t r i c i n t e r v e n t i o n , r e s p o n s e to c o n v e n
t e m p o r o m a n d ib u la r j o i n t s . T h e
s y m p t o m s s u c h as s le e p a n d a p p e t it e
t i o n a l d e n t a l o r s u r g ic a l t r e a t m e n t is
a t r ic w o r k - u p
d is t u r b a n c e s m a y b e p a r t o f th e c l i n i c a l
l i k e l y to b e c o m p lic a t e d b y p s y c h o lo g i c a l
c h o s o c ia l
p ic t u r e .
d if f ic u lt ie s .
s o m a t iz a t io n te n d e n c ie s .
T hese
in d iv id u a ls
a re
o fte n
d e s c r ib e d a s c h r o n i c w o r r ie r s w i t h
p e r-
f e c t i o n i s t i c a n d o b s e s s iv e p e r s o n a l it y
F u r t h e r p s y c h ia t r ic e v a lu
e le
m a n d ib u la r r a n g e o f
in s t a n c e s , s u i c i d a l t h o u g h t s . V e g e t a t iv e
o f g u ilt a n d in a d e q u a c y , a n d , in
b it e
of
is c o n s is t e n t w it h
s tre s s o rs ,
th e
p s y c h i
d e p r e s s io n s ,
psy and
a t io n a n d t r e a t m e n t is r e c o m m e n d e d as D r . J a v id . T h e
o u t li n e d b y D r . K a p la n .
in c lu d e s
tr a it s .
lo n g
d if f e r e n t ia l d ia g n o s is fa c e s y n d r o m e
( t h a t is ,
v e r t ic a l m a x i l l a r y e x c e s s w i t h
s o m a t ic s y m p t o m s . C h r o n i c
D rs. H w a n g a n d S a n tu c c i ( o r th o ti c s , o c c lu s a l a n a ly s is ) . W e a g r e e w i t h t h e
s t r e s s - in d u c e d a u t o n o m i c a r o u s a l m a y
a s s e s s m e n t m a d e b y D r . J a v id . T h e r e
p e t e n c e , m e n t a lis
r e s u lt in
is d e f in it e ly
a p e r t o g n a t h ia ; m u s c le c o n t r a c t i o n h e a d
P s y c h o l o g ic a l d i f f i c u lt ie s c a n b e r e p r e s e n te d i n
g a s t r o in t e s t in a l d is t u r b a n c e s ,
m a s t ic a t o r y a n d c e r v ic a l
s e c o n d a ry
r e t r o g n a t h is m ) , m i c r o g e n i a , l a b i a l i n c o m m u s c le
s t r a in , a n d
a l l l i k e l i h o o d , r e la t e d
a c h e ; m a s t ic a t o r y a n d c e r v ic a l f i b r o m y a l
d e f o r m it ie s p r e v io u s ly d is
g ia ; b ila t e r a l t e m p o r o m a n d ib u la r c a p
s y m p t o m s o r p s y c h o g e n ic p a i n ( o r b o t h )
c u s s e d . D e n t a lly , th e re is a s ig n if ic a n t
s u lit is ; e x o g e n o u s d e p r e s s io n ; f o r w a r d
a lt h o u g h
s k e le t a lly b a s e d m a lo c c lu s io n
th a t ha s
h e a d p o s t u r e a n d l i m i t e d c e r v ic a l r a n g e
n o t b e e n c o rre c te d b y r o u t in e o r t h o d o n t ic
o f m o t i o n ; p s y c h o s o c i a l s t r e s s / a n x ie t y ;
tre a tm e n t. T h is
a n d b r u x i s m ( F i g 1).
h e a d a c h e , i n s o m n i a , x e r o s t o m ia , a m o n g
f ib r o m y a lg ia , i n
o th e r s y m p to m s .
to th e j a w
E v id e n t c o n v e r s io n
s o m e w h a t le s s p r e v a l e n t a r e
s t i l l se e n i n p r o d u c in g
t h is p r o f i l e ty p e . I f a p a i n le s io n
is p r e s e n t , th e p a in
t o le r a n c e is l i k e l y to b e lo w e r e d s e c o n d a r y to d e p r e s s io n . M y i m p r e s s i o n
fro m
a d d r e s s e d f o r lo n g - t e r m s t a b iliz a t io n . I t is a d v i s a b le t o a d d r e s s t h e m u s c le
th e
p s y c h o m e t r ic p r o f i l e is a n a c u t e d e p r e s
p o in t m a y n e e d to b e
d is o r d e r f ir s t . A l o n g
w it h
Summary and conclusion
b io f e e d b a c k /
s i o n / a n x ie t y s y n d r o m e . T h e r e is a h i g h
stre s s m a n a g e m e n t a n d p h y s i c a l th e r a p y ,
The
p r o b a b ilit y
w e w o u ld
p ro to c o l
th a t th e o r ig in a l p h y s ic a l
in s t it u t e o r t h o t ic c a re w it h
te a m
re c o m m e n d e d th a t
in c lu d e d
a
tre a tm e n t
o ra l
m u s c le -
c o m p la in t s h a v e a s u b s t a n t ia l d e g re e
a f l a t p la n e ( m u s c le n e u t r a l iz i n g ) s p l in t .
n e u t r a liz in g s p lin t ; b io f e e d b a c k / m u s c le
o f p s y c h o l o g i c a l o v e r la y . I f a n o r g a n i c
The
r e e d u c a t io n / s t r e s s m a n a g e m e n t ; p h y s i c a l
p a t h o lo g ic c o n d it io n
m u s c le r e la x a n t w o u ld c o m p le m e n t s p l i n t
t h e r a p y ; p s y c h o lo g i c a l c o u n s e lin g ; a n t i
u se.
d e p r e s s a n t m e d ic a t io n ; n o n s t e r o id a l a n t i
D r. D o n lo n ( d i r e c t o r , F a c ia l P a in R esearch C en ter). T h i s i s a p a t ie n t w i t h
a n t m e d ic a t io n ; p r e s u r g i c a l o r t h o d o n t ic s ;
t o le r a n c e
is
lik e ly
is p r e s e n t , p a in
to
b e lo w .
I lln e s s
use o f a n N S A I D
a n a lg e s ic a n d a
i n f la m m a t o r y m e d ic a t io n ; m u s c le r e l a x
b e h a v io r w i l l t e n d to b e a b n o r m a l. I
a ls o n o t e t h a t o n th e B e c k D e p r e s s io n
In v e n to ry ,
th e
p a t ie n t
s c o re d
in
th e
m o d e r a t e t o s e v e r e ly d e p r e s s e d r a n g e .
a
u n iq u e
T h e d e p r e s s io n is c h a r a c t e r iz e d b y f e e lin g s
p s y c h ia t r ic
in t e r p la y
of
c o n d it io n s .
o r g a n ic P h y s ic a l
a n d o r t h o g n a t h ic m a x i l l o f a c i a l s u r g e r y . A
and e v a l-
a
c a s e r e p o r t w a s u s e d to illu s t r a t e
m u lt id is c ip lin a r y
a p p ro a ch
to
th e
Donlon-O thers : M ULTIFACTORIAL FACIAL PAIN DIAGNOSIS ■ 319
TIMI D I S O R D E R S
d is tr e s s a t th e p r e s e n t t im e a n d t h a t h e r
CLINICAL
ROUNDS
d i a g n o s is a n d
t r e a t m e n t o f f a c ia l p a in .
O f s ig n if ic a n c e
w a s t h e c o e x is t e n c e o f
is
a d v is a b le . A t h o r o u g h p a t ie n t e v a lu a t io n
o r g a n i c a n d p s y c h i a t r i c p a t h o lo g i c c o n
a n d a c o m p r e h e n s iv e t r e a t m e n t r e g im e n
d it io n s
in
a r e r e q u ir e d f o r o p t i m u m
la t e d ,
th e
t h is p a t ie n t . A l t h o u g h tw o
a s p e c ts
m e rg e d
u n re in
th e
a m in im u m
a y m p t o m o lo g y . S u c c e s s f u l tr e a tm e n t is
tio n s . T h e r e c o g n iz e
n a t u r e o f th e p a t ie n t ’ s illn e s s .
m a x i l l o f a c i a l a lg o lo g y .
o ra l an d
r e c o g n iz in g d e f o r m it y ,
and
t r e a t in g
m ig h t
th e s o m a t iz a t io n
not
th e s k e le t a l
have
a id e d
th a t w a s ca u se d b y
t e n d e n c ie s . A
r e c o g n iz in g
in
th e
p s y c h i
s y m p to m s
of
d e p r e s s io n a n d h e r “ l o n g , s h y , a n d s a d ” p h y s i o g n o m y m i g h t s u c c e s s f u lly a d d r e s s h e r m e n ta l s ta tu s w it h o u t a lle v ia t in g th e p a i n
c a u s e d b y h e r m u s c u lo s k e le t a l
s ta tu s . A
d e n t is t c o r r e c t i n g th e p a t ie n t ’s
b it e
m ig h t
o v e r lo o k
s k e le t a l d e f o r m it y s y m p t o m o lo g y s p e c ia lt y
th e
and
u n d e r ly in g
th e c o n v e r s io n
w i t h o u t th e b e n e f it o f
o f m u lt id is c ip lin a r y
c o n s u l
t a t io n . F o r c o m p li c a t e d p a i n d is o r d e r s o f th e h e a d a n d n e c k , th e m u lt i s p e c i a l t y a p p ro a ch
is
w e ll- t r a in e d c l i n i c i a n
m ust
th e m u lt if a c t o r ia l n a tu r e o f
m a x illo f a c ia l s u rg e o n ,
a b a te m e n t o f p a in a t r is t
r e s u lt s w i t h
o f m e d ic o le g a l c o m p li c a
b a s e d o n r e c o g n i t i o n o f th e m u l t i f a c t o r i a l An
DISORDERS
o r g a n ic a n d p s y c h ia t r ic c lin ic ia n s
e s s e n t ia l. 5
A
te a m
b a la n c e
320 ■ JADA, Vol. 120, March 1990
of
--------------------------- J'A D )A \ ---------------------------
T h e authors thank Dr. M arianne P. T ru ta for editorial review and Ms. Ann Pearce and Ms. Lori Bodhaine for their manuscript assistance. Dr. Donlon is director, the Facial Pain Research Center, University of the Pacific, 2155 Webster St, San Francisco 94115. He is clinical associate professor, Diagnostic Sciences, University of the Pacific, and m aintains a private practice. Dr. Kaplan is attending psychiatrist, Facial P ain Research Center; clinical professor, diag n o stic sciences, U niversity of the Pacific; and in private practice, care of the health professional. Dr. Javid is attending surgeon, Facial Pain Research Center and associate professor, oral and maxillofacial surgery, University of the Pacific. Dr. Harness is attending behavioral therapist, Facial Pain Research Center, and clinical assistant professor of diagnostic sciences, U niversity of the Pacific. He is a clinical psychologist whose private practice is limited to head and neck pain and post-traumatic
stress disorders. Ms. Shultz is a registered physical therapist and consultant, Facial Pain Research Center, whose private practice emphasizes care of head and n e c k /T M J patients. Dr. R om e is atte n d in g psy chologist, Facial Pain Research Center, on the staff, Psychiatry Liaison, at Pacific Presbyterian Medical Center, whose private practice focuses on psycho metric evaluation of pain. Dr. Hwang is attending d e n tist, F acial P ain R esearch C enter; c lin ic a l in stru cto r, diagnostic sciences, U niversity of the Pacific; and m aintains a private practice in general dentistry. Dr. Santucci is attending dentist, Facial Pain Research Center; clinical instructor, diagnostic sciences, University of the Pacific, and has a private practice in general dentistry. Address requests for reprints to Dr. Donlon. 1. Donlon WC, Jacobson AL. Maxillofacial pain. Am Fam Physician 1984;30:151-63. 2. Eversole LR, Stone CE, Matheson D, Kaplan H. Psychometric profiles and facial pain. Oral Surg Oral Med Oral Pathol 1985;60:269-74. 3. H arness MC, Eversole LR, D o n lo n WC. Comparison of clinical characteristics in myogenic, T M J internal derangement and atypical facial pain patients. Clin J Pain (In press). 4. Eversole LR, Machado L. Tem porom andibular jo in t internal derangem ents an d associated n e u romuscular disorders. JADA 1985;110:69-79. 5. Strain JJ, Hamerman D. Ombudsman (medicalpsychiatric) rounds. An approach to meeting patientstaff needs. Ann Intern Med 1978;88:550-5.