Case reports have several important functions in chiropractic care. They show us what is happening in the world of chiropractic care when it comes to presentations for certain conditions, how chiropractors are supporting the nervous systems of people with these conditions, and what the body does in individual cases when we support that nervous system. Case reports can also act as a signal boost – “Hey, has anyone else seen this in practice? Maybe it’s time to look further into it…” And thus, they can signal larger studies.
But every now and then, a case comes along that is novel and even surprising. These ones make us think – what more could there be to this story, and has anyone else seen something similar happen in their practice? Today’s article is one of those. While we know there are twelve cranial nerves, four of which affect the mouth and tongue, usually when we read chiropractic case reports about these, they pertain to infants or the facial or trigeminal nerves sometimes implicated in facial or migraine pain or jaw dysfunction. But how about a 76-year-old man presenting with hard-palate pain behind his left lateral incisor tooth? Not something we usually see in chiropractic practice.
That’s what makes this case so interesting. While chronic orofacial pain is thought to affect up to 7% of the population over the lifespan, some people never present for care for this pain which could be dental or neuralgic in its origin. [1]
In the present case, the gentleman in question presented with a chief complaint of tooth and oral pain he had suffered for two years. He had visited several health providers, including dentists, neurologists, physicians, acupuncturists and others about this and had been offered multiple pharmacological interventions, including acetaminophen-codeine, Orajel, oxcarbazepine and others. However, the pharmacological results were described as “palliative” rather than curative, and other healthcare providers described as ‘not beneficial’. [1]
At the point he presented for care, both hot and cold foods were problematic and provoked pain, as did any physical touch to the area. He described the pain as “a continuous ache with occasional throbbing and sharpness”, and he rated the pain as an 8/10 on the numerical pain scale.
When the chiropractor examined him, it was ensured that he didn’t have any markers of underlying visceral or emergency pathology before a thorough history and examination were taken. Mild postural results included anterior head carriage and anterior shoulders bilaterally, but there were no other changes. There were no abnormal results or masses detected upon palpation of the head or skull. All lymph nodes were normal, as were pupils, facial expressions and visual inspections to the area. Given the nature of the presentation, neurologic and orthopaedic tests were thorough (and listed in the original case report referenced below). Following these tests, a working diagnosis of “chronic greater palatine neuralgia” was suspected – meaning the palatine nerve stems through the Trigeminal Nucleus (and Trigeminal Cranial Nerve) and Pterygopalatine ganglion (which innervates the hard palate in the mouth) were involved.
A four-week course of care was commenced using multimodal care. This consisted of chiropractic manipulations (adjustments), HVLA adjustments to the cervical spine, craniofacial manual therapies, activator-assisted adjustments to the frontal and maxillary sinuses as well as manual suture mobilisation across the sagittal suture (which runs along the side of the skull from behind each eye in parallel lines from the top of the forehead to the crown of the skull. Laser therapy was also involved.
In the initial follow-up, the patient reported no reductions or changes. However, he stuck at it for four weeks. At the fourth follow-up, he noted that it was “less bothersome” and an “on and off” problem where it had been continuous before. The frequency and severity of the pain were both reducing, and he agreed to come back for a fifth visit.
At this point, he had reduced from an 8/10 on the numerical pain scale to a 6/10 – a difference of 25% in just five weeks. This was significant and even hopeful. However, the patient had hoped for greater results in a shorter time and ceased care. He then returned after a month, claiming that the pain had increased. He recommenced care and then ceased again after two weeks before any objective measurements could be gained again.
While this lack of adherence to care is a blow both for literature and for the patient, the 25% reduction in pain over a short course of care does prove interesting. What may have occurred if he stayed under care for longer, we cannot predict. Larger studies pertaining to effect sizes over key time periods would help draw some conclusions here, but given hard-palate pain is so poorly represented in chiropractic literature, there is a lot to examine here.
So what’s the takeaway? There may just be more to these cranial nerves in adulthood than we thought.
REFERENCE:
Buffamonte, M., Mattina, C., & Dimond, M. (2023). CHIROPRACTIC MANAGEMENT OF ATYPICAL HARD-PALATE PAIN: A CASE REPORT. Journal of Contemporary Chiropractic, 6(1), 100–108. Retrieved from https://journal.parker.edu/index.php/jcc/article/view/277
