An Unusual Case of Oro-Facial Chronic Pain ^†

1. Introduction

Fibromyalgia syndrome is a common form of diffuse musculoskeletal pain and fatigue (asthenia), which affects approximately 2% of world population.

The term fibromyalgia means pain in the muscles and fibrous connective structures (ligaments and tendons). This condition is called a “syndrome” because there are clinical signs and symptoms that are simultaneously present [1,2].

Fibromyalgia mainly affects the muscles and their insertions on the bones [3,4]. Although it may resemble an articular pathology, it is not arthritis and does not cause deformity of joint structures. Fibromyalgia is actually a form of extra-articular rheumatism or soft tissue.

The fibromyalgia syndrome lacks laboratory alterations. In fact, the diagnosis depends mainly on the symptoms the patient reports. Some people may consider these symptoms to be imaginary or unimportant. Over the past 10 years, however, fibromyalgia has been better defined through studies that have established guidelines for diagnosis. These studies have shown that certain symptoms, such as diffuse musculoskeletal pain, and the presence of specific algogenic areas for acupressure (tender points) are present in patients with fibromyalgia syndrome and not commonly in healthy people or in patients suffering from other painful rheumatic diseases. Tender point may be present at the level of temporo-mandibular junction and may overlap with temporo and cranio-mandibular disorders [5,6,7,8].

2. Therapeutically Approach

The anti-inflammatory drugs used to treat many rheumatic diseases do not show important effects in fibromyalgia. However, low doses of aspirin, ibuprofen and paracetamol can give some pain relief. Central analgesic drugs can reduce the painful symptoms of the fibromyalgic patient. Cortisones are ineffective and should be avoided due to their potential side effects. Drugs that facilitate deep sleep and muscle relaxation help many fibromyalgia patients to rest better. These drugs include tricyclic antidepressants (amitriptyline) and selective serotonin reuptake inhibitors (SSRIs) (paroxetine, fluoxetine) and other predominantly muscle relaxant drugs but structurally similar to antidepressants (cyclobenzaprine).

3. Exercise and Physical Therapies

Two of the main goals of fibromyalgia treatment are muscle stretching and training techniques for painful muscles and the gradual increase in cardiovascular (aerobic) fitness. Low or no impact aerobic activity, such as walking, cycling, swimming or exercising in water is generally the best way to start an exercise program.

4. Alternative Therapies

Even the so-called unconventional therapies such as dietary supplements or non-pharmacological treatments such as biofeed-back, acupuncture, gentle exercise and yoga can have positive effects on the symptoms of the fibromyalgic patient.

5. Case Report

39-year-old man suffered from significant chronic pain to arms, legs and extended to all body, non-restorative sleep, chronic fatigue, cutaneous rushes (Figure 1a,b). The chronic pain was referred to face, mouth and temporo-mandibular junction also. The patient was referred to a rheumatologist and then to a dermatologist. Blood testing was then performed: rheumatoid factor, anti-nuclear antibodies, anti-nDNA antibodies research, anti-ENA antibodies, and anti-cyclic citrullinated peptide antibodies were all negative. The dermatologist diagnosed atopic dermatitis. The patient was diagnosed with Fibromyalgia syndrome by the rheumatologist (FMS).

The onset of lower back pain, restless legs, and morning stiffness occurred one month before the visit. The symptoms were first described as severe pain. One-month later, lower back pain and legs pain forced the patient to bed rest. Similar symptoms of lower back pain during the following 2 months were attributed to the same cause. These episodes affected life quality and mobility, and forcing patient to bed.

The symptoms increased progressively and constantly. Migrant cutaneous rushes extended to hands, arms, neck, chest, legs and feet. A modest improvement was observed during summer and hot weather conditions, in particular during holydays. These had considerable impact on the everyday life, affecting social interaction and professional performance.

The ineffectiveness of pharmacological therapies in FMS came to patient’s knowledge. The patient was prescribed selective serotonin–norepinephrine re-uptake inhibitor (SNRI) (i.e., paroxetine 10 mg die) and he referred a reduction in pain, cutaneous rushes and chronic fatigue.