Temporal artery ultrasonography for the diagnosis of giant cell arteritis: a case report.

Orofacial pain is a worldwide pain problem, with many patients unable to find appropriate diagnosis and treatment. Orofacial pain includes pain arising from the odontogenic and nonodontogenic structures in the head and neck region. Dental clinicians need to have a thorough knowledge and skill to diagnose, manage, and treat patients with odontogenic pain or refer patients for treatment of nonodontogenic pain to specialists such as orofacial pain specialists, neurologists, otolaryngologists, and rheumatologists. More often, dental practitioners diagnose patients with a temporomandibular disorder (TMD), and when treatment is ineffective, term it "atypical facial pain." The first requirement for effective treatment is an accurate diagnosis. Dental clinicians must be aware of giant cell arteritis (GCA), a chronic large-vessel vasculitis, primarily affecting adults over the age of 50 years, as it frequently mimics and is misdiagnosed as TMD. GCA is associated with loss of vision, and stroke and can be a life-threatening disorder. Therefore, diagnostic testing for GCA and differential diagnosis should be common knowledge in the armamentarium of all dental clinicians. Historically, temporal artery biopsy was considered the definitive diagnostic test for GCA. Temporal artery ultrasound (TAUSG), a safe and noninvasive imaging modality, has replaced the previous diagnostic gold standard for GCA, the temporal artery biopsy, owing to its enhanced diagnostic capabilities and safety profile. The present case report describes a patient with GCA, and the role TAUSG played in the diagnosis. Case report: A 72-year-old woman presented with left-sided facial pain, jaw claudication, dysesthesia of the tongue, and episodic loss of vision of 2 years' duration. She was diagnosed with and treated for a myriad of dental conditions including endodontia and temporomandibular joint therapy with no benefit. A thorough history and physical examination, combined with serologic analysis, led to the diagnosis of GCA and TAUSG, which confirmed the diagnosis. Conclusion: This report underscores the responsibility of differential diagnosis and early recognition of GCA facilitated by TAUSG in optimizing treatment outcomes as a viable, noninvasive diagnostic tool. (Quintessence Int 2024;55:336-343; doi: 10.3290/j.qi.b4938419).

Persistent Idiopathic Dentoalveolar Pain: Is It a Central Pain Disorder?

The International Classification of Orofacial Pain (ICOP) describes idiopathic pain as "unilateral or bilateral intraoral or facial pain in the distribution(s) of one or more branches of the trigeminal nerve(s) for which the etiology is unknown. Pain is usually persistent, of moderate intensity, poorly localized and described as dull, pressing or of burning character." Several diagnoses are included in the ICOP Idiopathic pain section, burning mouth syndrome and persistent idiopathic facial and dentoalveolar pain. This article, with a representative case presentation, briefly discusses common features that may lead to a common central cause for a variety of peripheral complaints.

Sensory Changes Related to Dental Implant Placement: A Scoping Review.

AIMS: To perform a scoping review of the literature to elucidate the occurrence of nerve damage related to dental implant placement and the factors causing the sensory changes. METHODS: An extensive electronic search was conducted using the Cochrane Library, Medline via Ovid, PubMed, Wiley Online, Science Direct, CINAHL, and the Google Scholar databases from the year 1950 to 2020. RESULTS: The search resulted in 1,067 articles, out of which 76 were selected for this review. The articles were categorized as literature review articles, retrospective studies, prospective studies, and case series/case reports. Altogether, 2,526 subjects were assessed retrospectively, with 5.27% transient and 1.39% persistent sensory changes, and a cohort of 2,750 subjects were followed prospectively, with 6.22% transient and 1.31% persistent sensory changes. A total of 336 subjects were enrolled in various case reports and case series, with 5.95% transient sensory changes and 84.52% persistent neurosensory changes. The articles included were not of high quality and have variations in their study designs and reporting procedures, with limited sensory change data to include in this study. CONCLUSION: After surgical placement of dental implants in 5,612 patients, the incidence of transient sensory changes was 5.63%, and the incidence of persistent sensory changes was 6.33%. Factors affecting the incidence were: mandibular location of the implant, with the inferior alveolar nerve as the most commonly affected nerve. The common symptoms reported were paresthesia and dysesthesia. Age and gender were among other factors, for which data were not available in all the articles.

Secondary trigeminal neuralgia diagnosed in orofacial pain setting as epidermoid tumor.

This case report describes the rare occurrence of an epidermoid tumor compressing the ipsilateral trigeminal nerve resulting in secondary trigeminal neuralgia. MRI is the imaging modality of choice for the diagnosis of secondary trigeminal neuralgia. The epidermoid tumor was discovered by an orofacial pain specialist after reassessing the MRI study, previously reported as normal. Clinicians encounter a diagnostic dilemma when the clinical picture is not consistent with the MRI reports, clinical presentation, and expected results of treatment. The reassessment of the MRI and discovery of the epidermoid tumor resulted in a prompt referral to a neurosurgeon with a successful treatment outcome.

The relation of temporomandibular disorders and dental occlusion: a narrative review.

OBJECTIVE: The term temporomandibular disorders (TMDs) encompasses a variety of disorders of the temporomandibular joint (TMJD) and the associated musculature (MMD). Occlusion and its role in the genesis of TMDs is one of the most controversial topics in this arena. The objective of the narrative review was to summarize the implications of TMDs and its relationship to dental occlusion in two scenarios: 1) TMD as an etiologic factor in dental occlusal changes; 2) The role of dental occlusion as a causative factor in the genesis of TMDs. DATA SOURCES: Indexed databases were searched from January 1951 to August 2021 using the terms TMJ, TMD, temporomandibular disorders, temporomandibular joint, and dental occlusion. CONCLUSION: There is lack of good primary research evaluating true association and showing the cause-and-effect relationship between dental occlusion and TMD. Systematic reviews suggest that the role of occlusion as a primary factor in the genesis of TMDs is low to very low. However, a variety of TMDs can lead to secondary changes in dental occlusion. Distinction between the two is paramount for successful management.

Diagnosis and management of traumatically induced hemicrania continua and neuropathic pain secondary to facial gun shot wound.

Near fatal gunshot wound to the face results in lifesaving surgery and restorative procedures. Chronic pain followed. This is the probable first case report of posttraumatic hemicrania continua and its successful management.

Hemicrania continua secondary to neurogenic paravertebral tumor- a case report.

OBJECTIVES: Hemicrania continua (HC) is one of the trigeminal autonomic cephalalgias (TAC), where sympathetic dysfunction and autonomic dysfunction resulting in parasympathetic over activation with some evidence of sympathetic inhibition have been suggested as probable causes. However, cases of hemicrania continua secondary to sympathetic dysfunction due to neurogenic paravertebral tumor impinging on the sympathetic chain has not been previously reported. In this case, the probability of the sympathetic dysfunction was more likely based on the clinical features and management. CASE PRESENTATION: A 23-year-old female presented with a chief complaint of right unilateral pain in the retro-bulbar, head and facial region for the past three years. An initial MRI of the brain was negative, whereas an MRI of the spine was advised to rule out a cervicogenic origin of the pain. The MRI revealed a well-defined mass lesion within right paravertebral region at T3 indicative of a neurogenic tumor. The patient was diagnosed with probable hemicrania continua secondary to neurogenic tumor impinging on adjacent sympathetic chain. A trial of indomethacin 75 mg/day was advised, which provided complete relief of the headache. The patient was referred to a neurologist for management of the neurogenic tumor. CONCLUSIONS: Headache disorders may be secondary to pathologies and comprehensive evaluation and accurate diagnosis are essential. Knowledge of neuroanatomy is paramount to understand and explain underlying pathophysiological mechanisms. Multidisciplinary management is essential in complex orofacial cases.

Nummular Headache - a Case Report of a Rare Entity.

PURPOSE OF REVIEW: The purpose of this manuscript is to shed light on systematic work-up of a diagnostic challenge such as nummular headache (NH), and to summarize the relevant literature on NH. RECENT FINDINGS: The specific nature of the shape of the pain site is usually characteristic of NH. Multiple modalities of investigation including succinct imaging are necessary to successfully rule out other similar conditions. A 26-year-old female patient of Asian-Indian origin presented to the clinic with the chief complaint of chronic persistent left parietal headache for more than 10 years, which has been worsening over the past few days with no specific identifiable trigger. The diagnosis of nummular headache is challenging and confusing due to the rare occurrence and inadequate references in the literature. Appropriate imaging was done, which revealed no pathology that could explain the headache presentation. These findings are consistent with our diagnosis of nummular headache, and helped in the successful management of the case.

Entrustable Professional Activities in Postgraduate Orofacial Pain Programs.

Entrustable professional activities (EPAs) are a curriculum development and learner assessment tool that ensure a trainee is able to safely translate the skills they have learned during residency into unsupervised clinical practice. Although EPAs are used extensively across various health professions worldwide, dentistry is just beginning to call for their development at both the predoctoral and postgraduate levels. Given the complex, multifactorial nature of orofacial pain disorders and the need for an interdisciplinary approach to management, the specialty of orofacial pain is well suited to embracing EPAs to ensure program graduates are prepared for practice. Therefore, 10 EPAs have been developed in a combined effort from program directors from every CODA-accredited postgraduate orofacial pain residency program.

Chronic orofacial pain, cognitive-emotional-motivational considerations: A narrative review.

The following material was presented to an esteemed group of colleagues, Chinese physicians and stomotologists, friends and fellow panellists from around the globe at the Core China Conference, Nanjing China. Modern medicine accepts that a dichotomy exists between the mind, psyche and emotions and the rest of the body as if they function independently, having little downward up upward influence, one on the other. However, history teaches a different lesson. The influence of the emotional state of the patient plays a significant role effecting hormonal, neuroimmunological and peripheral modulatory factors influencing the pain experience. This brief discussion reviews the roots of modern Western Medicine in Traditional Chinese Medicine, and how we have come back to the realisation of the mind-body concept in treating the patient as a single entity and not as a collection of systems.

Minimally Invasive Trigeminal Ablation: Long Buccal Nerve.

AIMS: To describe a technique of minimally invasive trigeminal nerve ablation of the long buccal nerve that was performed at a tertiary care academic medical center. METHODS: This case describes a 44-year-old woman with refractory left long buccal nerve neuropathy following a dental procedure. After failing medical management, she was taken for nerve exploration, which revealed no nerve discontinuity or neuroma formation. She was therefore counseled regarding the risks and possible benefits of a novel minimally invasive trigeminal nerve thermoablation of the long buccal nerve technique. RESULTS: Postoperatively, the patient experienced mild anesthesia along the long buccal nerve division and no longer experiences any allodynia or hypersensitivity. Additionally, she no longer requires any additional medical therapy or interventions. CONCLUSION: Minimally invasive trigeminal nerve ablation of the long buccal nerve may be effective surgical intervention in treating refractory neuropathic pain in cases of no structural nerve defects. However, long-term well-designed studies are required to fully define its role.

The Effect of Nonstrenuous Aerobic Exercise in Patients with Chronic Masticatory Myalgia.

AIMS: To evaluate the effect of nonstrenuous aerobic exercise on chronic masticatory myalgia (CMM) patients and healthy controls (HC) by means of mechanical temporal summation (TS) and response to mechanical stimulation (RMS) performed on the dominant forearm. METHODS: A total of 30 patients diagnosed with CMM and 30 pain-free HCs were first evaluated for maximum number of steps (MNS) on a stepper machine for 1 minute. Additionally, they completed the Generalized Anxiety Disorder (GAD-7), Graded Chronic Pain Scale (GCPS), and Jaw Functional Limitation Scale (JFL) questionnaires. On the second visit, RMS, mechanical TS, exercise-induced hypoalgesia (EIH), blood pressure, pulse pressure, and heart rate were assessed prior to and immediately, 5, 15, and 30 minutes following 5 minutes of stepper exercise at 50% MNS. RESULTS: Compared to HCs, CMM patients demonstrated increased mechanical TS and less efficient EIH. Mechanical TS scores were reduced in both groups; however, the HC reduction was more robust and persistent. CMM patients demonstrated a delayed reduction in RMS following exercise in contrast to an immediate reduction in HCs. GAD-7, GCPS, and JFL scores for CMM patients were higher than for HCs and were associated with baseline pain intensity but not with EIH or TS. CONCLUSION: These findings suggest that, compared to HC, CMM patients' pain modulation is both suppressed and has a different effect duration and timing pattern. Further research should explore the mechanisms and clinical relevance of the delayed hypoalgesia and the inhibitory effect on TS induced by nonstrenuous aerobic exercise in CMM patients.

Presentation of cysticercosis of the lateral pterygoid muscle as temporomandibular disorder: A diagnostic and therapeutic challenge.

Orofacial pain can often be the chief complaint of many systemic disorders. Cysticercosis involving the lateral pterygoids may cause limitation of mouth opening and may mimic clinical symptoms of a temporomandibular disorder. A 37-year-old female presented with 1-month-old complaint of limited mandibular range of motion. She reported a similar episode a year earlier and was diagnosed with a temporomandibular joint disorder by her primary dentist. Comprehensive intra- and extra-oral examinations were performed, which revealed a limitation of mouth opening accompanied by mild limitation of contralateral excursion. A magnetic resonance imaging revealed a ring-enhancing lesion within the left pterygoid muscle suggestive of cysticercosis. The patient was referred to her primary care physician for further treatment and given physical therapy (stretching exercises) to improve mouth opening. One week later, she developed lesions in the arm and trunk. Further ultrasound imaging of the abdomen and the forearms confirmed the diagnosis of cysticercosis. She was treated with albendazole, physiotherapy, joint stabilization appliance, and had eventual complete recovery. This case emphasizes the importance of diagnosis of a systemic condition that may have serious implications, if untreated, and the importance of a comprehensive evaluation, workup, and multidisciplinary management.

Orbital pseudotumor presenting as a temporomandibular disorder: A case report and review of literature.

BACKGROUND AND OVERVIEW: Orofacial pain has multifactorial causes and is often a diagnostic challenge. Misdiagnosis can result in morbidity or mortality due to misdirected and inappropriate treatment. A delay of necessary treatment, in cases of ominous illnesses, may result in its perpetuation or progression. The authors present a case report that illustrates these possibilities. CASE DESCRIPTION: This case report describes a 36-year-old woman with the chief symptom of painless, limited mandibular movement. She also reported restricted movement of the left eye. She was previously diagnosed and treated for a traumatic right inferior alveolar nerve neuropathy, migraine, myofascial pain, and bilateral temporomandibular joint disk displacement with minimal benefit. Eventually she sought an orofacial pain evaluation, presuming her problems were related to a temporomandibular disorder. A complete history and comprehensive clinical evaluation including a cranial nerve screening evaluation, intraoral and extraoral examinations, an evaluation of the masticatory system, and dental radiographs were performed. The cranial nerve screening examination found painful, restricted eye movements. Magnetic resonance revealed a large, soft tissue mass in the inferolateral wall of the left orbit with soft tissue components in the infratemporal fossa and pterygoid space, involving the lateral pterygoid muscle and insertion of the temporalis muscle. The patient was referred to appropriate medical specialties and the diagnosis of orbital pseudotumor was confirmed and the patient was treated appropriately. CONCLUSIONS AND PRACTICAL IMPLICATIONS: The case emphasizes the importance of a comprehensive evaluation of a patient with preexisting orofacial pain when new symptoms arise or if there is a change in existing symptoms.