TMJ Pain and Temporal Tendonitis with Autonomic Features
This article reveals the complex nature of co-dependent structures neurally linked with the temporomandibular joint (TMJ) that can produce pain. Many of us know that facial and cranial pain are too often a challenge that yields disappointment for the patient and clinician. No one enjoys leaving an exam room unable to help yet another refractory headache patient. Hopefully, this article will shed some light on a patient suffering autonomic features that appear to be stimulated or perhaps originated by TMJ pain.1
The progression of painful symptoms and autonomic signs in a 59 year-old male with a history of controlled diabetes started three years ago following motor vehicular trauma. Neurologist-prescribed meds were of some benefit, however, the predominant pain symptoms did not respond adequately to the medications. The steps taken to attempt to diagnose the source of pain started with a referral to a dentist who constructed and fitted an anterior acrylic splint. The intent of the splint was to treat the symptoms focused at the temporomandibular joint on the right side. Unexpectedly, the use of the splint stopped the autonomic features previously noted by the neurologist.
As with many things that start well, this splint did not end well. There was more wrong than initially met the eye. Severe pain started six weeks after wearing the splint. The patient then stopped wearing the splint, and for a few days felt a little better, but the temple headache, retro-orbital headache, and jaw joint and ear pain progressively increased to a 8-10 on the visual analog scale and occurred almost daily. It is important to note that the right-sided autonomic features such as eyelid drooping, conjunctival injection, and tearing of the right eye stopped when the acrylic splint was first fitted and worn. The symptoms noted at the six week period were then worsened with reinsertion of the splint. This phenomenon is often a sign of temporal tendonitis co-existing with a TMJ problem. The new symptoms—oriented in the region of the temple, eye, TMJ, and ear—stopped with local anesthetic infiltration of the lateral and medial temporal tendons.2 Pain relief lasted about 5 days before returning. After a series of four blocks and the addition of vitamin B-12, corticosteroid, and Sarapin (by High Chemical), each block still failed to promote healing.
After explaining radiofrequency thermoneurolysis (RFTN) to the patient, it was performed at the temporal tendon insertions and it stopped the classic pain presented.
However, at the 7 day post-op visit, the patient started having severe retro-orbital headache. Palpation of the insertion of the sphenomandibularis muscle3 increased the existing retro-orbital headache. Local anesthetic infiltrations stopped the headache but only for a short period of two days. We decided to reinsert the anterior acrylic splint to unload the jaw joint, and the patient has been asymptomatic since its reuse. This experience suggests that the pain of the sphenomandibularis muscle was secondary to the TMJ dysfunction.
This patient presented with symptoms of trigeminal autonomic cephalalgia (TAC) and TMJ and temporal tendon-related pain symptoms. Though a large man, his mandibular maximum opening was 40 mm (normal is 45-55 mm). To everyone’s surprise, the use of the acrylic splint stopped the TAC and it has not yet returned. The course of treatment of this patient’s painful symptoms included the initial TMJ splint, injection of temporal tendons, RFTN of temporal tendons, injection of sphenomandibularis muscle insertion, and reinstitution of the TMJ splint.
It is known that a patient can have multiple sources of pain and referred pain. In this patient’s case, the jaw joint and the temporal tendons were partially independent of one another as primary pain producing structures, but had the capacity to refer pain from one structure to another. This feature of co-involvement found in complex pain cases requires the inclusion of a dentist in the referral pathway as initiated by the Neurologist since important treatment nuances are, in part, specifically and uniquely in the dentist’s training. It is important to add that the dental occlusion, or the way the teeth fit, can play a contributing role as well. Fortunately, this patient was seen by an astute Neurologist who recognized the TAC and the need for splint treatment of the deranged jaw joint. It is worth noting that TAC cases and Fibromyalgia cases can mask the TMJ-related symptoms that may be present due to the headache and diffuse pain often encountered. At no point after the initial TMJ/splint treatment did the autonomic features return in this patient’s case.