What are the possible diagnoses and treatments for jaw pain?

Jaw Pain: Differential Diagnosis and Treatment

Most Likely Diagnoses

Dental pathology is the most common cause of acute jaw pain and should be ruled out first, while temporomandibular disorders (TMD) represent the leading non-dental cause, affecting 5-12% of the population. 1, 2

Acute Causes (Typically Unilateral)

Dental and Oral Pathology (Most Common Overall)

• Dental infections, caries, pulpitis, and periodontal disease cause the majority of acute mandible pain 2
• Pain is typically unilateral, localized within the mouth, sometimes difficult to pinpoint to a specific tooth 1
• Oral mucosal diseases (lichen planus, herpes zoster, herpes simplex, recurrent oral ulceration, Sjögren's syndrome) present with pain associated with visible lesions 2
• Post-extraction complications and oral antral fistulas can cause persistent pain with oral and nasal discharge 1, 2

Maxillary Sinusitis

• Acute maxillary sinusitis can occur after dental infection or treatment to upper premolars or molars, especially extractions 1, 2
• Imaging may reveal foreign bodies in the antrum requiring surgical closure 2

Salivary Gland Disorders

• Salivary stones cause intermittent pain characteristically occurring just before eating, with tenderness on palpation of the involved gland 2
• Bimanual examination reveals slow or absent salivary flow from the affected duct 2
• Ultrasound imaging is the preferred diagnostic modality 1, 2

Chronic Causes

Temporomandibular Disorders (TMD) (Most Common Non-Dental Cause)

• TMD affects 5-12% of the population, predominantly females aged 20-40 years 2
• Encompasses muscle pain, disc displacement with or without limitation in opening, and joint pathology that can coexist 2
• Associated with comorbid conditions including back pain, fibromyalgia, headaches, depression, and chronic widespread pain 1, 2, 3
• Depression and catastrophizing significantly increase risk of progression to chronic pain, with up to 30% of acute TMD cases becoming chronic 2

Neuropathic Pain Syndromes

• Trigeminal neuralgia: Paroxysmal attacks of sharp, shooting, electric shock-like pain triggered by light touch, washing, cold wind, eating, or brushing teeth, with refractory periods between attacks 2, 4
• Glossopharyngeal neuralgia: Unilateral pain deep in the ear and/or back of tongue, tonsils, and neck, triggered by swallowing, coughing, or touching the ear; syncope can occur in rare cases 2, 4

Life-Threatening Diagnoses That Cannot Be Missed

Giant Cell Arteritis (Critical in Patients >50 Years)

• Presents with jaw claudication (pain with chewing), temporal region pain, scalp tenderness, visual disturbances, fever, and malaise 2, 4
• Physical examination reveals absent temporal artery pulse, temporal artery tenderness, and possible tongue cyanosis 2, 4
• Laboratory testing shows markedly elevated ESR and C-reactive protein 2, 4
• Requires immediate high-dose corticosteroid therapy (minimum 40 mg prednisone daily) to prevent permanent vision loss; do not delay treatment while awaiting temporal artery biopsy 2, 4
• Temporal artery biopsy must be obtained within 2 weeks of starting treatment 4

Malignancy

• Facial pain can be secondary to primary cancer or metastasis 1
• Tumors of salivary glands can cause intermittent pain, particularly when malignant with perineural invasion 4

Diagnostic Approach

Essential History Components

• Timing: onset, duration, periodicity 1
• Location and radiation: within nerve distribution 1
• Quality and severity 1
• Aggravating/relieving factors: hot, cold, sweet foods, prolonged chewing, eating, brushing teeth, touching face, weather, physical activity, posture, stress, tiredness 1
• Associated factors: clenching, bruxing habits, locking or clicking of jaw joint, altered sensation, nasal/eye/ear symptoms 1
• Comorbidities: headaches, migraines, chronic widespread pain, fibromyalgia 1
• Impact: sleep, mood, concentration, fatigue, beliefs, quality of life 1
• Psychological assessment: depression, catastrophizing, family history (TMD has genetic predisposition), social history, significant life events 1

Physical Examination

• Extraoral: visual inspection for color changes, swellings, skin lesions; palpation of lumps or salivary glands; examination of muscles of mastication and head/neck muscles for tenderness, trigger points, muscle hypertrophy; temporomandibular joint movement including crepitus; cranial nerve examination 1
• Intraoral: teeth for decay, mobile teeth, excessive wear facets (indicating bruxism), occlusion, ability to open; oral mucosa for soft tissue lesions 1
• For patients >50 years: palpate temporal arteries for tenderness, nodularity, or absent pulse 4
• For suspected neuropathy: light touch testing in all three trigeminal divisions to identify trigger zones or sensory abnormalities 4

Investigations

• Validated questionnaires: Brief Pain Inventory, Beck Depression Inventory, Hospital Anxiety and Depression Scale, McGill Pain Questionnaire, Oral Impacts on Daily Performance (OHIP) 1, 5
• Laboratory: ESR and C-reactive protein for suspected giant cell arteritis or autoimmune disorders (Sjögren's syndrome) 1, 4
• Imaging for dental pain: local X-rays, dental panoramic tomographs for bony lesions or cysts 1
• Ultrasound: preferred for salivary gland pathology 1, 2
• MRI: required to exclude tumors, multiple sclerosis, or neurovascular compression in trigeminal neuralgia 2, 4
• CT scans: may reveal insidious chronic dental infection mimicking TMD 6

Treatment Approach

For TMD (Most Common Non-Dental Cause)

Initial conservative management is most effective:

• Manual physical therapy techniques including maneuvers to resolve muscular trigger points, techniques to lengthen muscle contractures, and myofascial release 5
• Low-resistance exercise and transcutaneous electrical nerve stimulation to improve joint stability and reduce pain 5
• NSAIDs for symptomatic relief; topical treatments such as lidocaine patches and capsaicin 5
• Thermal therapies (hot/cold packs to jaw area or hot baths) provide effective relief for 91% of patients 3
• Cognitive behavioral therapy and relaxation techniques for patients with psychological components 5, 7
• Dental occlusion therapy (oral splinting) is commonly used but has insufficient evidence for or against its use 7

For Trigeminal Neuralgia

• First-line treatment is carbamazepine 1
• Neurosurgery reserved for poorly controlled patients 1, 4

For Giant Cell Arteritis

• Immediate high-dose corticosteroids (minimum 40 mg prednisone daily) 2, 4

Critical Diagnostic Pitfalls

Do not miss giant cell arteritis in patients over 50 years old with jaw claudication—delayed recognition can result in irreversible vision loss. 2, 4

• Chronic dental infections can mimic TMD; laboratory examination (C-reactive protein) helps detect latent infection 6
• Overlooking psychological factors (depression, catastrophizing) increases risk of chronicity in TMD and reduces treatment success 2
• Avoid invasive, permanent, or semi-permanent treatments before attempting noninvasive therapies, as they have potential to cause irreparable harm 7
• Lack of diagnosis in TMD patients significantly impacts daily life and quality of life 1
• TMD patients often develop chronic pain syndrome and may benefit from antidepressants or cognitive behavior therapy 7