I had an interesting TMD case recently that was a learning experience in terms of differential Dx. I thought I would share this learning experience with you.
Subjective: Pt reports has been doing invisalign. Was in MVA 4/13, had disc replacement C5-6, lumbar fusion. Also had lumbar disc replacement in 2010. In 2010, was able to return to working out. After the MVA, had PT, DC, MT, no help. Cervical spine feels better. Lumbar spine feels sharp, dull, aching - Sx worse with forward bending, lying flat > 20-30 min.
Insidous onset 10/1/14, was in standing room concert. That night noticed that left masseter was sore. Felt that right front teeth were the only part occluding, (shifted to R). Lined up better with invisalign, pain went away, did not last after removing. Removed invisalign at night for 3 days, felt better. After having orthodontist do prolonged work for 45 minutes, flared up. Currently occlusion is normal, but pain still exists in L masseter, felt in zygomatic arch and masseter belly. Sx rated 3/10 at best, and 7-8/10 at worst. Sx chewing, talking, yawning. Sx better with avoidance.
Also reports HA, temporal.
Objective: fair sitting posture
key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension
rot/flex Left FP Right FN
LRF Left FN Right FN
MRE Left FN Right FN
Trunk rot Left FN Right FN
Myofascia: tender and hypertonic in left masseter and temporalis patterns
Mandible depression, 28, deflects 2 mm to Left
lateral excursion Left 6 mm Right 2 mm
after IASTM and TMJ mobs, mandible depression 33, no deflection, pain in TMJ persisted, but masster pain abolished.
The subjective consisted of a good amount of Pain Science Education, on thresholds, movements, beliefs. The patient had left after the session feeling much better in his facial area, but the TMJ area still had moderate pain. This along with a concurrent improvement in mandible ROM quantity, and quality had both of us feeling hopeful about the case.
I often ask my patients to follow up by email within the next two days, whether or not they are better, worse, or no change. He replied later the next day stating he woke the next day, and the swelling in his left facial area had returned. I told him on the first day that about the possibility of neurogenic inflammation, but he did not buy it - luckily for him!
Another email follow up, stating because the recurrence of his spontaneous swelling, he ended up researching possible causes of facial swelling that recurs. It turns out that one of the diagnoses that popped up during his Dr. Google search was tooth abscess. He followed up with his dentist, who found a dental abscess in a left lower molar (which could also cause referred facial pain) and after a few days of anti-biotics, his facial pain, swelling and other complaints have cleared up 90%. He finished his last email stating if any stiffness or other mechanical like complaints remain after the infection is cleared up, he will make another follow up visit.
The bottom line is, on the second visit, I most likely would have had similar results, improvement in range, transient effects on pain, with no full relief. With no significant changes, I would have referred him to a specialist anyway. He just saved himself a visit and for once, Dr. Google came through!
A refresher on tooth abscess.
Keeping it Eclectic....