Bothering me

DRealDrZ · Jul 8, 2004

Someone asked me a question and I couldn't give her an answer. The question is basically this:
Guy has a problem with jaw pain. He doesn't take good care of his teeth so he has quite a few cavities. He has periodic pain that goes from his lower jaw up to his ear. Exacerbated sometimes when he chews food. What is the diagnosis?
a) trigeminal neuralgia
b) tooth abscess

I didn't know what to tell her...

barone ROCKS · Jul 8, 2004

i would say tooth abcess, as trigem neuralgia is also know as tic douloureux...a condition thats so painful that most people end up having the trigem cut

please can someone check this as its all from memory

ty

mountaindew2006 · Jul 8, 2004

well i got to thinking and i think that it may be caused by TMJ syndrome.

here check out the site.. http://www.sinuscarecenter.com/tmjaao.html

later

Smurfette · Jul 8, 2004

How about TMJ syndrome? That was my first thought with 'jaw pain'. Kinda need to know more history though.

How much pain is he in? Regardless, he should go to a dentist, they see TMJ and abscesses all the time.

If he had a tooth abscess, he'd be in a lot of pain most of the time, not intermittently. At least this is what I've seen personally. But you can't rule it out, especially if he has bad teeth.

Trigeminal neuralgia is also VERY painful; everyone who I've seen with this is virtually unable to work due to the pain--very debilitating.

DRealDrZ · Jul 8, 2004

I asked her about TMJ...she said it wasn't a "choice"
I'm really giving a short version of the question to avoid problems. Basically it said that there is pain that runs from the lower jaw up along the mandible up to the ear. It's worse when the person chews (following that line of pain). My question is if it's an abscess, wouldnt it hurt all the time? Maybe TMJ was an option and she missed "seeing" it. I don't know....

ItsGavinC · Jul 8, 2004

"Worse when the person chews" is probably the major clue for trigeminal neuralgia. Final answer.

mountaindew2006 · Jul 8, 2004

hmm...ITSGAVINC are u sure about that? if you go to that link that i put up it seems to imply trig neuralgia. IN addition, like the other guy said trig neural is VERY VERY PAINFUL. i dont kow....but it would be nice to know for sure.

later

Idiopathic · Jul 8, 2004

Temporal arteritis...jaw claudication following the external carotid. Thats my punch in the dark.

ItsGavinC · Jul 8, 2004

mountaindew2006 said:
hmm...ITSGAVINC are u sure about that? if you go to that link that i put up it seems to imply trig neuralgia. IN addition, like the other guy said trig neural is VERY VERY PAINFUL. i dont kow....but it would be nice to know for sure.

later

Well, yeah I'm sure, based on the available answers the OP gave us. TM problems certainly come to mind, but that wasn't one of the options. From the options given it would be trigeminal neuralgia.

Idiopathic · Jul 8, 2004

ALSO...this pain is in the distribution of V3, which is rarely the site of TN. I believe it is almost always in a V2 distribution (maxillary rather than mandibular). If I HAD to go with one of the two choices, I would pick abscess.

I am sticking with temporal arteritis though.

juliem3 · Jul 8, 2004

2 things- if you knew how old the "guy" is- it would rule out/in temporal arteritis. Mean age of onset is 70, almost never happens under 50yo. Also, this is picky, but TMJ pain usually starts at the ear and radiates outward. Not so much going from lower jaw TO the ear. Although it would hurt when you chew.
Still, I'd go with abscess for sure- the bad hygeine and cavities sounds like a giveaway.
my 2 cents

ItsGavinC · Jul 8, 2004

Idiopathic said:
ALSO...this pain is in the distribution of V3, which is rarely the site of TN. I believe it is almost always in a V2 distribution (maxillary rather than mandibular).

Not true. Trigger zones in BOTH V2 and V3 are the most common. This patient may or may not have duel trigger zones (let's face it, a jaw is a jaw is a jaw to lay people).

Without duel trigger zones, howver, V3 is the most common site of TN, then V2, and then V1 distribution.

The V3 distribution falls right in line with TN.

lindyloohoo · Jul 8, 2004

dude, we just got schooled by our nuero attending and were told that TMJ is a (quote) mickey mouse diagnosis (end quote) and should be ignored....the reason he said this, my pt a 78 yr old lady who lost all vision in her right eye due to temporal arteritis that was misdiagnosed as TMJ for 6 weeks. She was textbook for TA. However, sed rate was normal due to steroids for copd....so obvisously she didn't have TA (riiiiight....god forbid you listen to a history)

Idiopathic · Jul 8, 2004

ItsGavinC said:
Not true. Trigger zones in BOTH V2 and V3 are the most common. This patient may or may not have duel trigger zones (let's face it, a jaw is a jaw is a jaw to lay people).

Without duel trigger zones, howver, V3 is the most common site of TN, then V2, and then V1 distribution.

The V3 distribution falls right in line with TN.

You are right, except V2 appears to be slightly more common than V3, on its own. I think one of our textbooks remarked that V2 is almost ALWAYS the sits (it may have even been a question on COMLEX), so that is why I was confused. I still feel the pain is out of proportion though.

DRealDrZ · Jul 8, 2004

OK...
I talked to this person again...she says that TMJ was not a choice. Temporal Arteritis WAS a choice, but the person was younger (i.e. not 70) and something else that she couldn't quite remember pointed her away from it. She only gave me these two choices because everything else ruled things in/out (she's pretty smart, so I'd trust her judgement here).

DRealDrZ · Jul 8, 2004

Let's say that if this were on our medical boards, would it be "more likely" to be a "medical" diagnosis (trigeminal, TA, TMJ) vs. a "dental" diagnosis (abscess)? I was just thinking about that as well.

ItsGavinC · Jul 9, 2004

lindyloohoo said:
dude, we just got schooled by our nuero attending and were told that TMJ is a (quote) mickey mouse diagnosis (end quote) and should be ignored....the reason he said this, my pt a 78 yr old lady who lost all vision in her right eye due to temporal arteritis that was misdiagnosed as TMJ for 6 weeks. She was textbook for TA. However, sed rate was normal due to steroids for copd....so obvisously she didn't have TA (riiiiight....god forbid you listen to a history)

And that quote should be ignored...or at least in the context you are using it. I agree, in the case he was referencing a TM disorder should have been easily ruled out, however TM disorders aren't a mickey mouse diagnosis for people who truly suffer from them. In the case you referred to yes, but in all cases? No.

Perhaps I misunderstood what you wrote. If so, my fault. I'm certainly not here to make enemies--I browse the MD boards because I learn a lot from you guys.

ItsGavinC · Jul 9, 2004

DRealDrZ said:
Let's say that if this were on our medical boards, would it be "more likely" to be a "medical" diagnosis (trigeminal, TA, TMJ) vs. a "dental" diagnosis (abscess)? I was just thinking about that as well.

It's all in the way you view it. If it were on our dental boards I would be wondering if it would be more likely to be a medical diagnosis (TA) or a dental diagnosis (trigeminal, TMJ, or abcess).

So what does your friend think the answer is?

I'm thinking the exactly opposite of Idiopathic. I'm thinking the pain is out of proportion for a tooth abcess.

Idiopathic · Jul 9, 2004

I am set on TA...the diagnostic criteria mention 50 as the reasonable age cutoff.

DRealDrZ · Jul 9, 2004

She actually put Trigeminal Neuralgia...and the deciding factor was that (perhaps

)she was taking medical boards so it was more medical than "dental". Idio...she said that there were a few different things that directed her away from TA. I could definately buy your answer, though. Like I said, I didn't read the question, but with everything she told me I would have also narrowed it down to those two choices (not TA). The other choices were WAY off...off the top of my head I can't remember what she told me either...I think one may have been recurrent laryngeal nerve issue or something...crap I don't remember... :laugh:

barone ROCKS · Jul 9, 2004

i knew i was right

:laugh:

ItsGavinC · Jul 9, 2004

barone ROCKS said:
i knew i was right

Yo tambien.

lindyloohoo · Jul 11, 2004

ItsGavinC said:
And that quote should be ignored...or at least in the context you are using it. I agree, in the case he was referencing a TM disorder should have been easily ruled out, however TM disorders aren't a mickey mouse diagnosis for people who truly suffer from them. In the case you referred to yes, but in all cases? No.

Perhaps I misunderstood what you wrote. If so, my fault. I'm certainly not here to make enemies--I browse the MD boards because I learn a lot from you guys.

No enemies here. BTW... good luck on the NBDE tomorrow!! The attending, like most, believes his speciality is right all the time everytime. After he said it, all of us students looked at one of our fellow students who suffers from TMJ arthritis. I think he just wanted to make the point that just because the sed rate was low, doesn't mean that she didn't have TA. He also called tension headaches mickey mouse diagnoses. He would make these blanket statements in between lawyer jokes and fish stories so I think he was talking to hear himself sometimes. He kept us entertained on rounds however, so he's not all bad

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