Chronic Orofacial Pain Case Study

By Dr. John Dinan

When NSAIDs stop working…

At New York TMJ & Orofacial Pain, we specialize in diagnosing and treating complex orofacial pain conditions that often elude conventional dental and medical approaches. The following case study illustrates our comprehensive approach to chronic pain management. It highlights the limitations of traditional anti-inflammatory therapy and the importance of addressing central sensitization in persistent pain conditions.

Patient History

Mark, a 54-year-old male, presented with chronic neck and jaw pain. His symptoms developed gradually over a one to two-year period, coinciding with significant personal stress. Initially intermittent, the pain had progressed to become constant. His medical history revealed longstanding sleep disturbances and a demanding professional life, working approximately 60 hours weekly in a high-stress environment.

Of particular clinical interest was Mark’s self-medication pattern: daily consumption of 1800-2400mg of ibuprofen. This regimen, initially effective for pain management, had ceased providing relief. Despite this diminished efficacy, he continued the medication out of habit and apprehension about potential pain exacerbation.

Clinical Relevance

This pattern of high-dose, ineffective NSAID use is frequently observed in our practice. While we recognize NSAIDs as effective anti-inflammatory agents for acute pain management, their diminishing effectiveness in certain cases warrants closer examination.

Pain Science Framework

To understand Mark’s presentation, we must consider the three primary pain classifications:

1. Nociceptive Pain: This “conventional” pain results from tissue injury and subsequent inflammation. NSAIDs typically provide effective management for this pain category.
2. Neuropathic Pain: Pain arising from damaged neural tissue. NSAIDs generally provide inadequate relief for this classification.
3. Nociplastic Pain: Pain resulting from increased sensitivity within pain pathways, where the brain misinterprets sensory signals. This can occur independently or concurrently with other pain types. NSAIDs typically offer limited benefit for this pain category.

Case Analysis

Mark’s initial positive response to NSAIDs suggests his pain originated as nociceptive (inflammatory). However, the progressive sensitization of his pain pathways led to the development of nociplastic pain. Despite continued inflammation control via NSAIDs, pain persisted due to central processing abnormalities. This transition shifted the therapeutic target from peripheral inflammation to centrally sensitized pain pathways.

Therapeutic Approach to Centralized Pain

Several evidence-based strategies can address centrally sensitized pain pathways:

1. Therapeutic Education: Helping patients understand the concept of a “sensitized alarm system” and recognizing that ongoing pain doesn’t necessarily indicate ongoing tissue damage can significantly reduce symptom burden. This cognitive reframing often yields substantial clinical improvement.
2. Risk Factor Modification: Addressing factors that contribute to nervous system sensitization, particularly sleep dysfunction and chronic stress. Interventions range from lifestyle modifications to collaborative care with sleep medicine specialists, psychologists, or psychiatrists.
3. Central-Acting Pharmacotherapy: Medications with central nervous system effects, such as tricyclic antidepressants and gabapentinoids, can effectively modulate hypersensitive pain pathways.

Treatment Implementation and Outcomes

Mark’s treatment protocol included:

• Comprehensive education about pain neurophysiology
• Discontinuation of ibuprofen
• Nortriptyline prescription (a tricyclic antidepressant effective for pain pathway modulation)
• Trigger point injections to “reset” peripheral pain inputs

During several months of follow-up, Mark experienced gradual pain reduction, transitioning from constant to intermittent discomfort, and eventually achieving predominantly pain-free status. He successfully discontinued nortriptyline. Notably, occasional pain flares now responded appropriately to ibuprofen—once his central nervous system sensitization resolved, peripheral anti-inflammatory therapy regained effectiveness.

Clinical Implications

For patients with chronic pain conditions, particularly those affecting the orofacial region, treatment must often target central pain processing mechanisms rather than focusing exclusively on peripheral inflammation. While the pain is certainly not “imaginary,” it does involve central neurologic processing abnormalities in the brain and nervous system.

Dr. John Dinan is a Diplomate of the American Board of Orofacial Pain and the American Board of Dental Sleep Medicine. He practices at our New York City and Springfield, NJ, locations.