Diagnosis and treatment of orofacial pain in a patient ... · An ill-ﬁtting complete denture has...

CLINICAL REPORT

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THE JOURNA

Diagnosis and treatment of orofacial pain in a patient withunserviceable complete dentures: A clinical report

Audrey M. Selecman, DDS, MDSa and Swati A. Ahuja, BDS, MDSb

ABSTRACTAn ill-fitting complete denture has the potential to create pain and discomfort as well as conceal orconfound the diagnosis of other primary sources of orofacial pain such as trigeminal neuralgia.Guidelines of the American Academy of Orofacial Pain offer an evidence-based approach for theassessment, diagnosis, and management of orofacial pain. A complete and accurate differentialdiagnosis is paramount to the success of treatment as well as to the circumvention of unnecessarytherapy. The purpose of this clinical report was to emphasize an evidence-based approach to thediagnosis and treatment of orofacial pain in a patient with edentulism and a history of prolongeddenture wear. (J Prosthet Dent 2018;120:181-5)

Orofacial pain refers to painand dysfunction affecting mo-tor and sensory transmissionin the trigeminal nerve (TN)system.1 The pain source mayarise directly from tissuesinnervated by the TN, such asthe eyes, nose, ears, or mouth,or indirectly from tissues
innervated by other nerves but perceived by the brain ascoming from the tissue of the TN system.2 Lipton et al3
reported that almost 22% of the US population hasexperienced some form of orofacial pain. Prerequisites forsuccessful diagnosis and treatment of patients withorofacial pain largely depend on a universally accepted,valid, and reliable diagnostic classification system. TheInternational Research Diagnostic Criteria for Temporo-mandibular Disorders (RDC-TMD) consortium commit-tee has published several questionnaires, including theDiagnostic Criteria for Temporomandibular DisordersSymptom Questionnaire (RDC-TMD ConsortiumNetwork),4 the Jaw Functional Limitation Scale,5 theGraded Chronic Pain Scale,6 and the Oral BehaviorChecklist7 to assist in formulating the differential diag-nosis.4 Using inclusion and exclusion criteria, the paincan then be divided into categories suggested by theInternational RDC-TMD Consortium Network and theSpecial Interest Group on Orofacial Pain.4 These cate-gories are helpful in evaluating, communicating, andlocating the origin of orofacial pain, which can then betreated and managed accordingly.

A patient with edentulism presenting with orofacialpain and unserviceable removable complete dentures

ofessor, Department of Prosthodontics, University of Tennessee Health Scistant Professor, Department of Prosthodontics, University of Tennessee H

L OF PROSTHETIC DENTISTRY

Downloaded for scmh lib ([email protected]) at Show Chwan MemoriFor personal use only. No other uses without permission.

presents a challenge to diagnosis and treatment. As theprosthesis-supporting tissues remodel and the prostheticmaterials deteriorate, the oral environment becomessusceptible to damage through soft tissue abrasion,8

microbial colonization,9 compression of anatomic struc-tures such as the incisive papilla and metal foramen,10

and pathology such as papillary hyperplasia, epulis fis-suratum, and angular cheilitis associated with poor oralhygiene and the ill-fitting denture.11,12 Pain emanatingfrom the temporomandibular joint could also be theresult of loss of vertical dimension and malocclusion.13

However, referred pain from undiagnosed systemic dis-eases such as trigeminal neuralgia can mimic the oralpain typically associated with the sequelae of an unser-viceable denture.

Trigeminal neuralgia is a neuropathic disorder char-acterized by paroxysmal, shock-like pain attacks in themuscles and soft tissues innervated by the maxillary (V2),mandibular (V3), and, less often, the ophthalmic (V1)branches of the fifth cranial nerve.14 The pain is oftenunilateral and more common in women and those 50years of age and older. A recent classification accepted bythe American Academy of Neurology recognizes 3distinct categories of trigeminal neuralgia: idiopathic,

ience Center, Memphis, Tenn.ealth Science Center, Memphis, Tenn.

181

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Figure 1. Existing complete dentures with remnants of deteriorated resilient lining material. A, Maxillary denture. B, Mandibular denture.

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classical, and secondary.15 Classical trigeminal neuralgiapresents with neurovascular compression and morpho-logic changes of the trigeminal root.15 It is confirmedwith magnetic resonance imaging. Secondary trigeminalneuralgia, associated with major neurologic disease suchas a tumor or multiple sclerosis,15 is confirmed withconclusive magnetic resonance imaging or other diag-nostic tests. Idiopathic trigeminal neuralgia refers toneurologic pain without a definitive cause.15 Despite thedistinction, 99% of patients with trigeminal neuralgia canexperience pain through nonpainful stimuli such astouch, smiling, or shaving.15 These trigger zones can besmall, with targeted areas most commonly present in thecentral portion of the face and around the nose andmouth.

The taxonomy committee of the International RDC-TMD Consortium Network4 and the Special InterestGroup on Orofacial Pain in conjunction with the Amer-ican Academy of Orofacial Pain16 offer an evidence-based approach for the assessment, diagnosis, andmanagement of orofacial pain. The purpose of the pre-sent clinical report was to emphasize an evidence-basedapproach to the diagnosis and treatment of orofacial painin a patient with edentulism and a history of prolongeddenture wear.

CLINICAL REPORT

A 76-year-old white woman was referred to theDepartment of Prosthodontics, University of TennesseeHealth Science Center, Memphis, School of Dentistry, forevaluation of orofacial pain and replacement of unser-viceable complete dentures. The patient’s chief complaintwas recurrent and severe “electric shock-like” painradiating from the left ear to the chin for approximately 5weeks. She reported that the pain occurred every night ataround 11:00 PM and persisted with high intensity for 5to 20 minutes, followed by a lingering ache until she fellasleep. Massaging the area, change in bodily position,

THE JOURNAL OF PROSTHETIC DENTISTRY


application of heat or cold, or removal of dentures did notalleviate or decrease the intensity of the pain. The patientdid not experience the pain while sleeping, and it was notreproducible while awake during the day. Nothing ofnote precipitated or aggravated the pain. She had beengiven a prescription of ibuprofen (Motrin 800 mg;Johnson & Johnson Consumer, Inc) 3 times a day by thereferring dentist for the pain. She said the medicationwould “take the edge off,” but did not alleviate the pain.She had taken the analgesic medication sporadically for 2to 3 weeks. A thorough medical, dental, and psychosocialhistory was documented, followed by a clinical andradiologic examination.

Her medical history revealed that the patient was ingood health with no known allergies. She reported anegative history of orofacial trauma, sleeping disorders,substance abuse, surgery, or hospitalization. The pa-tient’s current social and financial circumstances createda significant amount of personal stress. The patient waswidowed and was in a long-term cohabitation rela-tionship with her current partner, who was kind andsupportive. However, he had end-stage renal diseaseand was undergoing dialysis. The patient also reportedstrained family relationships and a planned relocation.Nevertheless, the patient had a pleasant and graciousdemeanor.17,18

Her dental history revealed that the patient had hadall her teeth extracted at age 22. Complete dentures withan acrylic resin base and porcelain semianatomic teethwere fabricated and delivered shortly after the extractionsites had healed. The patient stated that she had beeninstructed to “never take the dentures out.” The patienthad worn the same dentures for a period of 55 years,removing them only to clean once or twice daily. Thedentures had been relined with a nonresilient liningmaterial 35 years before and a resilient relining material 1year previously. Remnants of the deteriorated liningmaterial were present in the dentures (Fig. 1). The patientreported using a large amount of denture adhesive.

Selecman and Ahuja


Figure 2. Denture-bearing areas. A, Maxillary arch. Papillary hyperplasia is shown on left posterior palate. B, Mandibular arch. Epulus is shown inanterior vestibular area.

Figure 3. Existing complete dentures. Patient exhibited pseudo-class IIIocclusal relationship.

Figure 4. Cone beam computed tomography scan depicted resorbedmandibular ridge and mental foramina positioned at crest of ridge.

August 2018 183

Clinical examination revealed localized inflammationof the maxillary ridge, especially on the buccal aspect ofthe left posterior ridge and the corresponding vestibularareas. A 1.5-cm diameter raised papillary lesion (papillaryhyperplasia) was seen on the left posterior palate(Fig. 2A).11 Other areas that demonstrated papillarysurface transformation included the rugae, soft palate,and right posterior maxillary ridge. The anterior maxillaryridge appeared to be smooth and exhibited a moderatedegree of mobility. The mandibular ridge had undergonesevere resorption in width and height (class IV),19 wasknife-edged, pink, and mostly nonkeratinized andexhibited a moderate degree of mobility. A small epulisfissuratum concurrent with the denture flange,measuring 4 mm in length and 2 mm in width, was notedin the anterior mandibular vestibular area (Fig. 2B).11 Noabnormalities were noted in facial reflexes. The mentalforamina were located on the crest of the ridge. However,their palpation did not elicit a pain response. Nonumbness was associated with the lower lip. Intraoralexamination of the complete dentures revealed a poor

Selecman and Ahuja


occlusal relationship; however, the porcelain dentureteeth displayed minimum wear. In maximum intercuspalposition, the dentures were in a pseudo-class III occlusalrelationship (Fig. 3). An evaluation of the patient’s profileand interocclusal distance suggested a loss of occlusalvertical dimension due to the resorption of theprosthesis-bearing tissues. The temporomandibularjoints exhibited normal mouth opening and no clicking,popping, crepitus, or deviation. Palpation revealed nofacial or cervical muscle tenderness or swelling.

The radiographic examination results were consistentwith those of the clinical examination, revealing severealveolar bone resorption in the maxilla and mandible.Cone beam computerized tomography scanningconfirmed that the mental foramina were positioned atthe crest of the mandibular ridge (Fig. 4). The foraminameasured 1 cm at the widest aspects. No overt signs ofdegenerative joint disease were evident.

A differential diagnosis for the origin of orofacial painwas created by noting specific inclusion criteria andruling out specific disorders.4 Three of 8 possible axis I



Figure 5. Existing dentures relined to establish increased occlusalvertical dimension and horizontal occlusal relationship.

Figure 6. Definitive complete dentures.

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(physical orofacial pain conditions) criteria were met. Thepatient’s personal stress level contributed to axis II(psychologic) factors associated with the patient’s painexperience. The differential diagnosis included thefollowing intraoral causes: epulis fissuratum, inflamma-tory papillary hyperplasia, tissue trauma, ill-fitting com-plete dentures; the neuropathic causes: trigeminalneuralgia, hyperzincemia, compression of the mentalnerve; and the extracranial and systemic causes: coronaryartery disease and myocardial ischemia.

The patient was initially advised to discontinue theuse of dentures, but she found this unacceptable. Sheagreed to limit denture wearing to social settings andeating. To improve fit and promote tissue recovery, thedentures were cleaned, disinfected, relined with aresilient material (Trusoft; Bosworth Co), andadequately relieved to ensure that the nerves exitingthe mental foramen were not compressed. The occlusalvertical dimension was increased during the reliningprocedure by approximately 2 mm (Fig. 5). The patientwas advised to avoid the use of zinc-containing den-ture adhesives to avoid hyperzincemia, associated withwidespread sensory and motor neuropathies.20 Thepatient was also instructed to discontinue the use ofthe ibuprofen to prevent chronic exposure and sup-pression of symptoms necessary for diagnosis.21 Thepatient was recalled and evaluated the following week.She was pleased with the improvement in fit, function,and comfort; however, she reported that the painpersisted with the same intensity.

Based on the description of the pain, the patient wasreferred to her primary care physician for further systemicevaluation. The results of an electrocardiogram andvarious cardiac function tests helped rule out cardiac-related causes of orofacial pain.22 However, neurolog-ical examination and neurological test results wereconclusive for atypical trigeminal neuralgia. The patient



was initially given a prescription of carbamazepine,200 mg orally 2 times a day.23 The patient indicated thatthe pain was relieved after the administration of the firstdose of carbamazepine. The patient was maintained onlow-dose carbamazepine.

The patient was recalled and evaluated every 2 to 3weeks for 4 months. She had no recurring painfulsymptoms, and inflammation and pathology of the oraltissues had resolved. The denture soft liner was reeval-uated and replaced as needed. Only after the pain hadbeen diagnosed, treated, and controlled were the defin-itive complete dentures fabricated (Fig. 6). The patientwas given oral hygiene demonstrations, provided withthe cleaning aids necessary to maintain hygiene of theprosthesis and the oral cavity, and given a printed copy ofdetailed home care instructions. She was placed on abiannual recall schedule to reevaluate the oral tissue forsigns of trauma and the prostheses for fit and function.She was advised to contact her dental and medical pro-fessional immediately if she experienced any reoccur-rence of orofacial pain.

SUMMARY

Not all types of orofacial pain disorders can be diagnosedor treated by a dental professional. Although treatingintraoral disorders is within the scope of the dental field,additional training is required to diagnose and treattemporomandibular disorders, primary headaches, andsleep disorders. Vascular and nonvascular intracranialpain, neuropathic pain, cervical pain, and extracranialand systemic causes of pain should be referred to anappropriate medical professional. Each differential diag-nosis should be pursued until the correct diagnosis isascertained. Eliminating the existing complete denturesfrom the list of orofacial pain differential diagnoses mayrequire fabrication of a treatment denture or modification

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August 2018 185

or tissue conditioning or relining the existing denture toan acceptable occlusal relationship.

This article demonstrates the importance of acomprehensive, multidisciplinary, systematic approachgrounded in evidence-based reports and reliable tech-niques to diagnose and treat orofacial pain effectively.Use of the Research Diagnostic Criteria methodologyrepresents an organized way for the clinician to develop adiagnostic rubric tree4; however, although the method-ology provides a systematic and stepwise approach, it hasyet to be validated.

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Corresponding author:Dr Swati A. AhujaUniversity of Tennessee Health Science CenterDepartment of Prosthodontics875 Union AvenueMemphis, TN 39163Email: [email protected]

Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.



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