Jaw Pain in an Adolescent Boy

Abstract

A 14-year-old boy was referred to the Department of Oral Medicine at the Hospital of the University of Pennsylvania in Philadelphia for evaluation and treatment of jaw pain. The patient described intermittent pain localized to the right mandible that had begun two years before, with no antecedent traumatic event. In addition, he described brief, stabbing, electric, shocklike pain that occurred when eating and also spontaneously. On a numerical rating scale of 1 to 10, he rated the pain at 10. He reported that each painful attack lasted 10 seconds and that this occurred several times a day. Between pain attacks, the patient reported mild-to-moderate dull pain localized to the right masseter muscle area. The patient also described having intermittent bilateral asymptomatic temporomandibular joint (TMJ) clicking. Reportedly, his dentist, in an attempt to control what the patient described as “muscle spasms,” had treated the patient with an oral appliance and physical therapy. His dentist had also ordered magnetic resonance imaging (MRI) with and without contrast of the TMJs, which were unremarkable for intracapsular pathology. At the time the clinician (A.P.) evaluated the patient at our clinic, his medical history, review of systems and family, and social and medication histories were unremarkable. He also was undergoing fixed orthodontic treatment without complications. The clinical examination revealed a wellnourished and well-developed adolescent boy without affective distress. The findings of the head and neck examination were unremarkable. Examination of cranial nerves II to XII showed that the patient had diminished sensation (hypoesthesia) to light touch with a cotton swab and to cold, and he could not recognize pinpricks localized to the distribution of the right mandibular division of the trigeminal nerve. Functions connected with the other cranial nerves—visual acuity and fields, equal and reactive pupils, eye movement, masticatory muscle strength, facial expression, elevation and symmetry of the palate and uvula, contraction of sternocleidomastoid and trapezius, and extrusion of the tongue—were grossly intact. The patient’s reactions to palpation of his cervical and masticatory muscles and TMJs were unremarkable except for mild-to-moderate tenderness of the right masseter muscle. The patient could open his mouth to a maximum of 48 millimeters without pain or deviation. His functional jaw movements, including eccentric and protrusive movements with and without resistance, were unremarkable and produced no TMJ sounds. On oral examination, the examiner found enlarged tonsils, but otherwise an absence of intraoral pathology. Maxillary and mandibular dentitions were banded with braces. Palpation of the right mandibular ramus area triggered the patient’s jaw pain (which was localized anatomically to the distribution of the right third division of the trigeminal nerve) that lasted approximately 30 seconds. After the pain, the patient experienced a refractory period during which the examiner’s attempts to trigger subsequent episodes were unsuccessful. After a few minutes, palpation of the right buccal mucosa area once again reproduced the pain attack. A panoramic radiograph showed that the patient had impacted third molars, but the results were otherwise unremarkable.