Sir, in August of 2016 a very fit and healthy 73-year-old female patient of mine developed intermittent severe pains in the occipital area bilaterally. Following a series of tests, a consultant rheumatologist prescribed prednisalone 25 mg per day but admitted to not having a definitive diagnosis.

In December 2016 the patient suddenly developed severe TMJ pain and although no occlusal disharmony in two intact arches was identified a soft-bite raising splint was provided. This gave some slight relief and the symptoms slowly subsided. The prednisalone was then at 10 mg per day.

In January 2017 she noticed that blood vessels in her temple were becoming prominent (but not painful) and then she experienced pain in her muscles of mastication on chewing (claudication) and was unable to finish a meal where meat required chewing.

An urgent appointment with the rheumatologist was sought. He diagnosed giant cell arteritis (GCA) and the prednisalone was increased to 60 mg. A significant number of patients with GCA (up to 20%) suffer problems with occlusion of the opthalmic artery and permanent blindness. Strokes are also more likely. It is therefore essential that high doses of prednisalone are given as soon as GCA is suspected as this massively decreases the incidence of eye problems.

As general dental practitioners we should be more aware of GCA and that pain on eating or other undiagnosed 'jaw pain', is a symptom. Also, an oral surgeon advised me that any instance of rapid onset TMJ pain in an older patient should be referred urgently and that a biopsy of the temporal artery would probably be carried out. It seems there may be a connection between patients with polymyalgia rheumatica (PMR) and GCA and a significant proportion of patients with PMR also get GCA. It may be that arteritis in blood vessels supplying muscles results in a diminished supply thereby giving rise to the symptoms of PMR. Where patients report a diagnosis of polymyalgia I will now ask them if there are any headaches or jaw pain, especially on eating.

1. London