During the course of the year, I invariably see a number of patients whose level of orofacial pain suffering is extraordinarily high. One such group includes patients who relate a history of an eating disorder, most commonly bulimia nervosa.
In these patients, there is often an absence of the typical physical findings found in those suffering from “TMD.” But, there are distinguishable features that help identify these patients – even if their history has not been readily shared.
Case Study – Marci
Consider Marci, a 26-year-old who reported the presence of daily and often debilitating jaw and face pain that was focused specifically at the jaw angles on the right and left sides. Her pain had been present for several years but had reached an “unmanageable level.”
Over the years, she had sought care and received a variety of pain and muscle relaxant medications. Episodically she had her neck and jaw muscle pain evaluated and treated by physical therapists, and subsequently, she received acupuncture and trigger point injections. At times she wore oral appliances to confront sleep bruxism, which was thought to be at the center of her suffering.
As a result of not realizing benefit, she abandoned care for an extended period of time before coming to my office.
Though she did not initially share her complete medical history, my examination findings began to provide an understanding of her persistent pain. Though she reported a history of sleep bruxism, there was no evidence of masseter hypertrophy nor was there excessive wear of the cusps of her back teeth or incisal edges of her anterior teeth.
Marci’s face was puffy, particularly at the jaw angles; a finding uncommon in most of our orofacial pain patients. Palpation of the masseters as they wrapped over the angle of the mandible prompted a marked pain response and physical withdrawal. Her TM joints, however, were not tender.
An examination of Marci’s teeth revealed a complete loss of dentin on the occlusal (biting) surface of the lower molars suggestive of chemical erosion in the presence of excessive acid.
Considering the information gathered, it was evident…
- Bruxism was likely not the cause of Marci’s pain.
- The source of the acid erosion on her teeth needed to be determined along with the origin of her jaw puffiness.
- The origin of the tissue sensitization in her masseter muscles needed to be uncovered.
Based upon past patient encounters a more probing medical history revealed a longstanding eating disorder. With that revealed, things began to fall into place.
With the knowledge that overstimulation of the parotid glands as a result of vomiting can lead to ductal hypertrophy, inflammation, and an appearance of swelling, one question had been answered.
In addition, as glandular overstimulation over time can lead to persistent irritability of the sensory nerve endings that run through the gland, the intense palpation pain reported over the mandibular angle and masseter as it overlaps the parotid was better understood. And with the origins of the intraoral acid revealed, the loss of enamel on the occlusal surfaces of the molars was clearly erosive in nature and not due to the friction of bruxism.
With a better understanding of the origins of her pain, now came the hard part. As the dominant part of Marci’s suffering was likely due to nerve sensitization, treatment options included a prescription for low dose nortriptyline and Botox injections in the masseter and temporalis muscles. Both therapies were directed towards improving nerve thresholds and reducing spontaneous activity in the trigeminal system.
In addition, a topical prescription medication containing a mixture of anesthetic, nerve membrane stabilizers, and anti-inflammatory medication was provided for her to rub over the masseter three times a day.
Four weeks into treatment, Marci rated her pain approximately 40% reduced and heading in the right direction. Three months after the first Botox injection, however, the pain crept back upwards but was not back to square one. A second Botox injection session provided more longstanding results and prompted her to continue her talk therapy and the other supportive efforts designed to diminish her suffering.
At this juncture, three years after her initial presentation, Marci seeks care at my office sporadically as she continues to rely on the nortriptyline and occasional Botox injections. She reports significant overall improvement – less pain and a happier existence.
Patients who suffer from eating disorders do not represent the majority of patients in my practice. However, they can -and often do, develop stubborn orofacial pain problems. While no treatment is a miracle cure, I am gratified that in Marci’s case, I was able to help.
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