What is the best approach to manage a 52-year-old female patient's recurrent episodes of severe sharp and achy pain in the right anterior mandible, accompanied by joint pain, with a history of chronic fibrosing osteomyelitis of the jaw and no relief from ibuprofen or hydrocodone?

Management of Recurrent Mandibular and Joint Pain Following Chronic Fibrosing Osteomyelitis

This patient requires a comprehensive biopsychosocial pain assessment with consideration of centralized pain mechanisms, followed by a trial of neuropathic pain medications (pregabalin or duloxetine) combined with physical therapy, given the episodic nature, widespread joint involvement, and failure of standard analgesics. 1

Clinical Reasoning and Diagnostic Considerations

Pain Pattern Analysis

The clinical presentation suggests a transition from localized osteomyelitis to a more complex pain syndrome:

• Episodic severe pain (10-14 days) with spontaneous resolution indicates a pattern inconsistent with active infection or structural pathology, particularly given negative imaging by endodontics 1
• Accompanying widespread joint pain ("throughout her joints") suggests centralized pain processing or a systemic inflammatory component rather than isolated mandibular pathology 1
• Failure of NSAIDs and opioids is characteristic of neuropathic or centralized pain mechanisms, not nociceptive pain 1

Critical Differential Diagnoses to Exclude

Before proceeding with chronic pain management, you must rule out:

• Giant cell arteritis: Mandatory consideration in any patient >50 years with new-onset facial/jaw pain and systemic symptoms; obtain ESR/CRP during next flare and consider temporal artery ultrasound or biopsy 1
• Recurrent osteomyelitis: While imaging is negative, obtain inflammatory markers (ESR, CRP) during a flare episode, not between episodes when they will be falsely negative 2, 3
• Temporomandibular joint disorder (TMD): The joint pain component warrants specific TMJ evaluation including jaw range of motion, palpation of masticatory muscles, and assessment for clicking/crepitus 1, 4
• Fibromyalgia: Widespread joint pain, episodic flares, and poor response to standard analgesics are hallmark features 1

Recommended Management Algorithm

Phase 1: Diagnostic Clarification (Next 2-4 Weeks)

During the next pain flare, obtain:

• ESR, CRP, CBC to capture inflammatory markers during active symptoms 1, 2
• Consider rheumatologic panel (RF, anti-CCP, ANA) given widespread joint involvement 1
• Formal TMJ examination including assessment of masticatory muscle tenderness, jaw opening measurements, and joint sounds 1

Between flares:

• Detailed pain mapping: Have patient document exact location of all pain sites during flares using a body diagram 1
• Screen for fibromyalgia using widespread pain index and symptom severity scale 1
• Assess for sleep disturbance, fatigue, and mood symptoms which commonly accompany centralized pain 1

Phase 2: Initial Treatment (Weeks 2-8)

Pharmacologic Management:

Start pregabalin as first-line neuropathic pain agent:

• Initial dose: 75 mg twice daily 5
• Titrate to 150 mg twice daily after 1 week if tolerated 5
• Maximum effective dose: 300 mg twice daily if needed after 2-4 weeks 5
• Rationale: Pregabalin has Level Ia evidence for neuropathic pain and is effective for sharp, shooting pain characteristics 1, 5

Alternative if pregabalin not tolerated:

• Duloxetine 30 mg daily, increase to 60 mg daily after 1 week 1
• Rationale: Duloxetine has dual benefit for neuropathic pain and comorbid mood symptoms 1

Non-Pharmacologic Management (initiate simultaneously):

• Physical therapy focused on jaw and cervical spine: 2-3 sessions per week for 6-8 weeks 1, 4

  • Gentle jaw mobilization exercises
  • Postural correction
  • Soft tissue massage of masticatory muscles
  • Evidence: Physical therapy has uniformly positive effects on pain in musculoskeletal conditions 1

• Consider occlusal splint fabrication if TMJ dysfunction confirmed on examination 1, 4

  • Wear at night initially
  • Evidence: American College of Rheumatology considers splints beneficial, safe, and reversible for TMJ dysfunction with documented improvement in symptoms 4

Phase 3: If Inadequate Response at 8 Weeks

Psychological intervention:

• Cognitive behavioral therapy (CBT) referral for chronic pain management 1
• Evidence: CBT has Level Ia evidence with weak-for recommendation for fibromyalgia and chronic pain conditions 1

Consider aerobic exercise program:

• Start with low-impact activities (walking, swimming, cycling) 20-30 minutes, 3-5 times weekly 1
• Evidence: Aerobic exercise has the strongest evidence (Level Ia, Grade A, strong-for 100%) for fibromyalgia-type pain 1

Multidisciplinary pain management referral if still refractory 1

Critical Pitfalls to Avoid

• Do not repeat antibiotics without clear evidence of active infection (positive cultures, imaging changes, or elevated inflammatory markers during flare) 2, 3
• Do not pursue additional surgical interventions on the jaw without objective findings; chronic fibrosing osteomyelitis can have prolonged courses but surgical re-exploration without clear pathology risks worsening pain 6, 7
• Do not dismiss the widespread joint pain as unrelated; this is a key diagnostic clue suggesting centralized pain mechanisms 1
• Avoid long-term opioid therapy; she already failed hydrocodone, and opioids are ineffective for neuropathic/centralized pain 1
• Do not attribute symptoms to "long COVID" without excluding other treatable conditions first; this is a diagnosis of exclusion 1

Monitoring and Follow-Up

• Week 2: Assess medication tolerance and side effects
• Week 4: Evaluate pain reduction (aim for ≥30% improvement); if none, increase pregabalin dose 5
• Week 8: Comprehensive reassessment; if <50% improvement, add CBT and exercise program 1
• Week 12: Consider rheumatology or pain medicine referral if inadequate response 1

Special Consideration: Semaglutide

• No established link between GLP-1 agonists and the pain pattern described
• Continue current dose if weight management remains a goal and no temporal relationship between medication changes and pain flares