In an orofacial pain practice where many patients have TMJ problems, it is not uncommon for a former patient to return for evaluation and treatment often many years later. At times the returning symptoms share a similar profile to what was managed earlier, and evaluation and treatment proceed down a familiar pathway.
Less frequently a patient returns and the symptoms that are reported immediately suggest the evaluation process must be moved in alternative directions.
This was the case when 83-year old Barbara returned after an eight year absence with what she described as irritating, though intermittent, pain on the right side of her face and jaw that at times felt like a toothache. When she had been seen eight years prior, her pain was also on the right side of her jaw and viewed as often acute and commonly increased with chewing.
Risk factors at that time included a changed chewing pattern due to the loss of teeth, widespread arthritis, and the recent passing of her husband.
At the time of Barbara’s initial presentation, her age and acute pain prompted a brain MRI along with TMJ imaging. As the brain MRI was unremarkable, intracranial pathology was ruled out. Ultimately, the examination findings along with mild arthritic changes in the right TMJ pointed to a local inflammatory problem with associated muscle pain, likely due to a changed chewing pattern…and grief.
Treatment led to symptom resolution.
This time, however, Barbara’s pain symptoms were either present or absent with no middle ground and not related to function. Full examination of the teeth and x-rays were not diagnostic of pulpal pathology and tooth pain could not be elicited with any form of peripheral provocation. Muscle and joint examination findings were just as unremarkable.
Most concerning was the symptom pattern of pain that would come and go in the distribution of the second and third division of the trigeminal nerve in an unprovoked fashion.
Based upon Barbara’s age, unremarkable examination, and spontaneous bouts of sharp pain, the diagnosis of trigeminal neuralgia was a strong diagnostic consideration. As a result, a brain MRI with contrast tracing the trigeminal nerve was obtained revealing “a mass lesion in the left posterior cranial fossa compressing the left trigeminal nerve, identified as a meningioma.”
Note: Although 90% of meningiomas (CNS tumors) are benign, once diagnosed the majority are surgically reserved to relieve neurological symptoms. A meningioma arises out of the membranes that surround the brain and spinal cord and as it grows often compresses adjacent nerves and blood vessels. These are slow-growing tumors and often exist without symptoms for many years. It isn’t clear what causes a meningioma but they occur later in life and more frequently in females.
With these findings in hand Barbara was referred to a neurosurgeon and is presently in the midst of considering surgical options and the risk-benefit ratio at her age.
If there is a moral to the story, it revolves around remembering this: when a patient returns after a long period of time for care, past encounters should not drive a preconceived diagnosis nor the direction of treatment.
Things are sometimes not what they seem to be!