Introduction
The two major yet rare clinical syndromes manifesting oral pain and jaw discomfort that have posed these clinical challenges for diagnosis to the maxillofacial surgeon are the first bite syndrome (FBS) and the Eagle syndrome (ES). Read on to learn the common link between them, how they differ, and your surgeon's management strategies in dealing with these complex orofacial conditions.
Why Are the Same Clinical Features Seen in Two Different Syndromes: First Bite and Eagle Syndrome?
Lower jaw or retromandibular pain is a common finding that links two major maxillofacial syndromes in the oral surgery field. Patients complain of the first bite syndrome (FBS). Eagle syndrome (ES) includes pain that is triggered frequently either upon biting or chewing food, earaches, limited mouth opening/ trismus, foreign body sensation in the oral cavity or the jaw, jaw pain, swelling, sensitivity, dysgeusia or altered sensation of taste, difficulty in swallowing (dysphagia), etc. to name the multiple clinical symptoms that are common amongst both these syndromes mentioned.
Now, how are these two syndromes related? What do they have in common, and how can your surgeon differentiate these two common syndromes from each other, with exact clinical symptoms? These questions that maxillofacial surgeons have posed over the last few decades have resulted in an extensive focus on medical research and literature to find answers as well. According to current description and clinical pathologies, the first bite syndrome and the Eagle syndrome are two different yet innately linked syndromes that affect the jaw or the face. The common feature between both these syndromes is retromandibular pain or lower jaw pain specifically. Let us look into the pathogenesis of each of these syndromes to understand how they are linked to each other and what are the management strategies that are adopted by your dentist or maxillofacial surgeon.
As you would have read above, the clinical features that are common in both the syndromes of FBS and ES are a diagnostic challenge for the maxillofacial surgeon, indeed, to detect or confirm the right underlying condition causing moderate to severe and persistent jaw pain. Further, medical and dental research highlights that in both these syndromes, there is a compression of nerves, muscles, and blood vessels in the jaw region, causing the patient to experience the symptoms listed above. The key lies in differentiating these two syndromes in terms of the cause or etiology.
1. First Bite Syndrome:
This condition was first described by Reverred Haubrich in 1986 and later elaborated and specified further by Reverred Neterville et al. in the year 1998.
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Pathologic Origin of First Bite Syndrome (FBS ) - It is mainly a jaw condition characterized by pain in the parotid and retromandibular regions of the upper and lower jaw regions, respectively, in affected patients. At meal times, especially while biting, patients face severe pain and discomfort. Because the first bite of the meal, upon contact with your posterior molars or teeth, while chewing food, is the trigger of pain, this came to be known as the First bite syndrome. Medical researchers on eliciting patient history found that FBS develops secondary as a condition in patients who have undergone surgery to the parotid gland or surgery in the para-cervical regions. Research demonstrates that because of the surgical trauma or the post-operative impact in the region of the parotid gland and the retromandibular regions, the jaw cells, as well as the parotid salivary gland (major salivary gland cells that have parasympathetic receptors, turn intensely hypersensitive and start contracting upon the first bite of the patient, i.e., when starting a meal. This subsequently tends to induce head and neck pain in severity or even cramps in the affected region of the patient, making the quality of life extremely difficult due to routine jaw discomfort. Often, in tumors of the parotid gland that have been resected by maxillofacial surgeons and then reconstructed through maxillofacial or reconstructive jaw surgery - in such complex cases, loss of parasympathetic receptors is quite possible leading to such hypersensitivity in the region of the parotid gland and in the lower jaw.
The maxillofacial surgeon, hence, needs to elicit the patient history Thoroughly in order to diagnose correctly FBS, which is directly linked to paracervical trauma or parotid gland post-surgical trauma in the face and jaw. The point to be noted and not confused by surgeons is that first bite syndrome /FBS is utterly different from Eagle syndrome (ES), which will be discussed below.
2. Eagle Syndrome - This is the condition in which the patient's stylohyoid ligament is severely affected or impacted. The stylohyoid ligament extends from the hyoid bone and the temporal styloid process, which is part of the skull's temporal bone and is one of the major supportive ligaments of the facial skeleton. Due to the mobilization of either ligament, direct trauma, or indirect trauma because of surgically induced anatomic nerve or blood vessel compression in this region of the face (as would occur commonly in jaw surgeries), Eagle syndrome would occur, resulting in patients experiencing severe pain orally and jaw discomfort accompanied by earache, limited mouth opening, altered taste, and difficulty in swallowing (note that all these features would be common to the FBS / first bite syndrome as well).
How to Differentiate and Manage First Bite Syndrome and Eagle Syndrome?
Though the clinical symptoms of first bite syndrome and eagle syndrome are similar, the differentiating factor between FBS and ES is that while in FBS, patients have surgical trauma to the paracervical regions, in ES patients, patients do not have any history of surgery to these facial regions (the parotid gland or the lower jaw region). The patients who are diagnosed with ES show ossification or damage to the stylohyoid ligament, which is the only factor that is caused by direct or indirect surgical trauma to this region.
While the management of ES would be focused by the maxillofacial surgeon on rectifying the stylohyoid ligament and its surgical correction, in FBS syndrome - the maxillofacial surgeon would initiate mainline gold standard treatment of BT (botulinum toxin) injection along with physiological saline in the painful or affected areas, which can be repeated every for to six months basing on the patient's symptoms to improve their quality of life and to prevent pain while chewing food.
Conclusion
To conclude, jaw pain or oral pain and discomfort is a major impediment to quality of life. The challenging diagnosis of FBS and ES based on the patient's past surgical or medical history can give maxillofacial surgeons insight into managing these conditions correctly and improve the scope for restoring the affected patient's jaw functions.
