What are the recommended steps for managing cheek pain and tenderness with no other symptoms?

Management of Isolated Cheek Pain and Tenderness

For isolated cheek pain and tenderness without other symptoms, begin with a systematic evaluation to rule out dental causes first, followed by assessment for sinusitis, temporomandibular disorders, and serious conditions like giant cell arteritis (if age >50), before considering chronic pain syndromes. 1

Initial Diagnostic Approach

Critical Red Flags to Exclude Immediately

• If patient is over 50 years old: Check for jaw claudication (pain with chewing), scalp tenderness, visual changes, fever, or malaise—these suggest giant cell arteritis requiring urgent ESR/CRP testing and immediate high-dose corticosteroids (minimum 40 mg prednisone daily) to prevent permanent vision loss 2
• Progressive pain with sensory changes: Consider malignancy, which can present as neuropathic pain—this requires imaging 1, 3
• Recent trauma or dental procedures: May indicate post-traumatic trigeminal neuropathic pain 1

Systematic History Taking

Document these specific characteristics 1:

• Timing: Continuous versus episodic pain, duration of each episode, and whether there are pain-free intervals 1, 3
• Quality: Sharp/shooting versus dull/aching versus burning 1, 3
• Aggravating factors: Does chewing worsen pain (suggests TMD, dental pathology, or giant cell arteritis)? Does light touch trigger pain (suggests trigeminal neuralgia)? Does eating initially trigger pain (suggests salivary stone)? 1, 2
• Location precision: Can the patient point to one specific spot, or is it diffuse and poorly localized? 1

Physical Examination Priorities

Extraoral Examination 1

• Palpate temporomandibular joint: Check for clicking, crepitus, or tenderness suggesting TMD 1
• Palpate muscles of mastication: Assess for tenderness, trigger points, or hypertrophy indicating muscle pain 1
• Palpate temporal arteries (if age >50): Check for tenderness, nodularity, or absent pulse suggesting giant cell arteritis 2
• Inspect skin: Look for color changes, swelling, or lesions 1
• Palpate salivary glands: Bimanual palpation may reveal stones or masses 2

Intraoral Examination 1

• Examine teeth: Look for decay, mobile teeth, wear facets (indicating bruxism), or percussion tenderness 1
• Check oral mucosa: Assess for soft tissue lesions, ulceration, or inflammation 1
• Assess occlusion: Evaluate bite alignment and jaw opening 1

Neurological Examination 1

• Test all three trigeminal divisions: Light touch in V1 (forehead), V2 (cheek), and V3 (jaw) to identify trigger zones or sensory deficits 1, 2
• Complete cranial nerve examination: Document any abnormalities 1

Diagnostic Algorithm Based on Findings

If Dental Pathology Identified

• Immediate dental referral for definitive treatment of decay, abscess, or periodontal disease 1
• Most dental pain is acute, unilateral, and specifically localizable to a tooth 1

If Muscle Tenderness Predominates (TMD)

• First-line management: Reassurance, patient education, and simple physiotherapy 3
• Avoid aggressive interventions initially—TMD often responds to conservative measures 1

If Pain Characteristics Suggest Neurological Cause

Trigeminal neuralgia features (sharp, electric shock-like, triggered by light touch, with refractory periods between attacks): 1, 4

• Order MRI to exclude secondary causes (multiple sclerosis, tumors, neurovascular compression) 1, 4
• Start carbamazepine as first-line treatment 4
• Note: Classical trigeminal neuralgia has paroxysmal attacks lasting seconds to minutes with mandatory refractory periods—not continuous pain 4

Continuous burning or aching pain (atypical facial pain/persistent idiopathic facial pain): 1, 3

• This presents as continuous, non-anatomical pain without paroxysmal attacks 4
• Start amitriptyline as initial treatment 3
• Consider cognitive behavioral therapy 1

If Salivary Gland Involvement Suspected

• Salivary stone: Pain characteristically occurs just before eating, with tender gland on palpation and slow/absent salivary flow from affected duct 2
• Order ultrasound imaging for diagnosis 2
• Refer to oral/maxillofacial surgery 2

If No Clear Cause Identified

For isolated cheek pain without objective findings: 1

• Avoid surgical procedures when pain is the only symptom without objective findings 3
• Consider persistent idiopathic facial pain, which is continuous, poorly localized, and non-anatomical 1, 4
• Trial of amitriptyline with cognitive behavioral therapy 3

Common Pitfalls to Avoid

• Do not assume all facial pain is dental: Only 42% of patients with trigeminal neuralgia may also have atypical facial pain features, and both conditions require separate treatment 5
• Do not delay corticosteroids if giant cell arteritis is suspected while awaiting temporal artery biopsy—vision loss is irreversible 2
• Do not perform invasive procedures for facial pain without clear structural pathology, especially when pain is the only symptom 3
• Do not miss the diagnosis by failing to distinguish continuous from episodic pain—this fundamentally changes the differential diagnosis 1, 4

When to Order Imaging

• MRI indicated: Any suspected neurological cause, progressive pain, sensory changes, or failed first-line treatment 1, 4, 2
• Ultrasound indicated: Suspected salivary gland pathology 2
• Dental X-rays indicated: Any suspicion of dental pathology 1

When to Refer

• Immediate referral: Suspected giant cell arteritis (to rheumatology/internal medicine) 2
• Urgent referral: Suspected malignancy or progressive neurological symptoms 1
• Specialist referral: Failed first-line treatment for neuropathic pain (to neurology) 3
• Dental referral: Any identified dental pathology 1
• Oral/maxillofacial surgery: Salivary stones or masses 2