History of Present Illness
Approximately ten days before she was seen, the patient described feeling that her jaw had dislocated while she was laughing. She had heard a "bump" and noticed that trying to open her mouth beyond a certain point caused pain in the right side of her face. The area was sore, visibly swollen, and painful to chew and yawn. When closing the mouth, the right posterior teeth made contact before the left ones. There were no joint sounds on either side during jaw movement and no previous history of joint sounds catching or locking. The trauma history was negative.
The patient was under considerable stress and had become aware of frequent jaw clenching. Her husband had a serious heart condition and was unable to work. He had cardiac bypass surgery three years before and was scheduled for angioplasty the next week. The patient was worried about her husband, their two teenaged children, finances, and health care costs. She admitted to using chewing gum in the past, but other parafunctional habits were denied. The patient had mild headaches that occurred less than once per month. She averaged 6-7 hours of sleep per night, which she judged to be less than adequate. Her jaw ached and the attached musculature felt tired on awakening.
The patient described her health as good and was due for her annual medical examination. Recent illness,hospitalization, and surgery were denied. A hysterectomy for cervical cancer had been performed in 1989 and the patient received medical treatment for parathyroid adenoma in 1996. A brief review of systems appeared unremarkable.
Current medications included: estrogen, methocarbamol (500 mg QID), and vitamin supplements.
Allergies: none known.
Tobacco, alcohol, and caffeine use were denied.
The patient had been married for thirty-two years.
She was employed fulltime as a legal assistant and enjoyed her work.
The patient was a well-nourished, well-groomed female in no apparent distress.
Vital signs: BP = 130/90, HR = 70, Temperature = 97.1° F (36.2° C).
Head and Neck: A firm, fixed swelling measuring approximately 3 cm diameter x 0.5 cm high was present in the right preauricular area, just below the TMJ. Cranial nerves V and VII were grossly normal, although the smile was slightly asymmetrical as shown here. The external auditory canals were occluded by wax.
The Temporomandibular Disease (TMD) exam followed the Research Diagnostic Criteria (RDC) for TMD.1 The patient indicated recent pain in both sides of her face. The left masseter muscle was mildly tender, and the right masseter was moderately tender to palpation. The lateral pole of the right TMJ was moderately tender, but not the posterior attachment. No TMJ sounds were heard on stethoscopy. Painless opening was limited to 15 mm interincisally. Maximum opening was only 25 mm and occurred with right preauricular pain. Lateral excursion of the jaw was 10 mm to the right, but only 6 mm to the left with right facial pain. No deviation was noted on jaw opening or protrusion.
photo of patient at initial examination Oral hygiene was excellent. The oral mucosa was unremarkable. The right parotid gland was non-tender and clear, serous fluid could be easily expressed from Stenson’s duct. The dentition was intact and well restored with mild wear in the anterior teeth.
Initial review of the panoramic radiograph was thought to reveal bifid mandibular condyles, a variant of normal. The maxillary sinuses were clear and their borders intact. There was a suggestion of recurrent caries in teeth #2 and #15.
Subsequent review of the panoramic film by an oral and maxillofacial radiologist indicated that there was also significant loss of bone density in the right ascending ramus and a loss of cortical integrity in the right condylar neck. Superimposition of air in the oropharynx over the right and left ascending rami made detection of this radiolucent area in the original film difficult.
Impression and Initial Treatment
The history and examination suggested an acute, non-reducing disc displacement of the right TMJ with possible rupture of the lateral aspect of the joint capsule. A lateral disc displacement would be quite unusual, and an MRI was recommended to confirm the diagnosis. The patient declined because her insurance company refused to provide benefits for treatment on the grounds that it was for a "TMJ condition."
Behavioral modifications were recommended: a soft diet and avoidance of clenching and excessively painful opening. Anti-inflammatory therapy was begun with six days of a systemic corticosteroid, methylprednisolone, followed by Sulindac, a non-steroidal anti-inflammatory drug (NSAID). The patient was already taking a muscle relaxant. Fabrication of a flat plane occlusal splint was recommended.
One Month Follow-Up
The patient was taking Sulindac as prescribed. Her right facial swelling was unchanged, but she could open her mouth more easily. Jaw rest and medication helped to ease constant pain in the right preauricular area, which had an average intensity of 5 on a scale from 0 (none) to 10 (worst imaginable).
The patient was still aware of clenching her teeth frequently. Her general dentist fabricated an occlusal splint that she wore at night and while concentrating at work. Maximum opening was 24 mm, with preauricular pain and jaw deviation to the right. Both masseter muscles were mild-moderately tender.
An MRI was again recommended but deferred. The patient’s husband had been told that his cardiac condition was terminal, and the family’s financial stability was of greater concern.
At her annual physical exam six weeks after her initial orofacial examination, the patient presented with "vague abdominal pain and weight loss." She had lost approximately 15 lbs., which she attributed to pain in her right jaw and limited ability to chew. She described having mild bloating but denied nausea, vomiting, cramping, diarrhea, or blood in her stool. An abdominal ultrasound was ordered and showed diffuse liver masses. Subsequent colonoscopy demonstrated an obstructing tumor of the left colon. A partial sigmoid colectomy was performed to remove a 3 cm, moderately differentiated adenocarcinoma. The patient received chemotherapy (type not specified in the available records), followed by 5000 cGy of 16 mv electron beam radiation therapy to the tumor mass in her mandible. She tolerated treatment well, with decrease in both pain and anesthesia in her jaw. She is currently living at home and working part time. She recently reported new metastases and a worsening prognosis.
Transcranial Radiographs and Magnetic Resonance Imaging
Transcranial (lateral) views of the TMJ’s (not shown) suffered from so much superimposition as to be of questionable value. A medical radiologist noted normal cortical surfaces of the mandibular and the temporal bones and an absence of anterior translation on opening. MRI was recommended for a more informative evaluation (see below).
The MRI report states, "The dominant finding is the presence of a mass lesion which involves the right mandibular ramus extending towards the right temporomandibular joint. This mass measures 3.5 x 2.8 x 3.5 cm. The mass extends into the pterygoid musculature medially and extends laterally into the buccal musculature. This is causing bony destruction of the right mandibular ramus extending to the level of the right TMJ joint and most likely represents a metastatic lesion. No evidence of metastatic disease involving the brain."