What are the next steps for a patient experiencing jaw pain on the opposite side of a recent crown replacement, with pain onset prior to the dental procedure?

Jaw Pain Contralateral to Recent Crown Replacement with Pre-Procedure Onset

This jaw pain is almost certainly unrelated to the crown replacement procedure since it began before the dental work was performed, and the pain is on the opposite side of the mouth from where the crown was placed. 1

Immediate Diagnostic Priorities

The timing and location of this pain require urgent evaluation to exclude life-threatening causes before considering benign etiologies:

Rule Out Giant Cell Arteritis (If Patient >50 Years Old)

• If the patient is over 50 years old, immediately assess for jaw claudication (pain worsening with chewing), temporal region pain, scalp tenderness, visual disturbances, fever, or malaise. 1, 2
• Examine for absent temporal artery pulse, temporal artery tenderness, or tongue cyanosis. 2
• Order ESR and C-reactive protein immediately if any of these features are present—do not delay corticosteroids (minimum 40 mg prednisone daily) while awaiting temporal artery biopsy, as vision loss from untreated giant cell arteritis is irreversible. 1, 2
• Temporal artery biopsy must be obtained within 2 weeks of starting treatment. 2

Exclude Dental Pathology on the Painful Side

• Perform a comprehensive dental examination of the painful side, including cold testing for pulpal vitality, periapical radiographs examining for apical changes, and panoramic radiograph to exclude other maxillofacial disease. 3
• Dental infections, caries, pulpitis, and periodontal disease cause the majority of acute mandible pain and are typically unilateral and localized. 1
• Direct microscopic examination should be considered to rule out incomplete tooth fracture if pain is tooth-specific. 3

Most Likely Diagnoses Given Pre-Procedure Onset

Temporomandibular Disorder (TMD)

• TMD is the most common non-dental cause of mandible pain, affecting 5-12% of the population with peak incidence at ages 20-40 years, and represents the leading diagnosis when dental pathology is excluded. 1
• TMD encompasses muscle pain, disc displacement with or without limitation in opening, and joint pathology that can coexist. 1
• The pain typically does not present with numbness and may be associated with comorbid conditions including back pain, fibromyalgia, and headaches. 1, 4
• Depression, catastrophizing, and psychological factors significantly increase the risk of progression to chronic pain, with up to 30% of acute TMD cases becoming chronic—these factors must be addressed early. 1

Salivary Gland Disorder

• Salivary stones in the submandibular gland cause intermittent mandible pain characteristically occurring just before eating, with tenderness on palpation of the involved gland. 1, 2
• Bimanual palpation may reveal the stone, with slow or absent salivary flow from the affected duct. 2
• Ultrasound imaging is the preferred diagnostic modality for salivary gland pathology. 1

Trigeminal Neuralgia or Neuropathic Pain

• Trigeminal neuralgia causes paroxysmal attacks of sharp, shooting, electric shock-like pain in the trigeminal distribution, triggered by light touch, washing, cold wind, eating, or brushing teeth, with a refractory period between attacks. 1, 2
• If pain is continuous rather than paroxysmal and associated with numbness, consider post-traumatic trigeminal neuropathic pain or atypical odontalgia. 4, 3
• MRI of the brain and trigeminal nerve is mandatory to exclude tumors, multiple sclerosis, or neurovascular compression. 2, 4

Maxillary Sinusitis

• Acute maxillary sinusitis can occur after dental infection or treatment to upper premolars or molars, though this would typically be ipsilateral to the dental work. 1
• Imaging may reveal foreign bodies in the antrum requiring closure by oral/maxillofacial surgeons. 1

Critical Diagnostic Workup

Perform a comprehensive cranial nerve examination including:

• Light touch testing in all three trigeminal divisions to identify trigger zones or sensory abnormalities. 2, 4
• Assessment for other neurologic deficits outside the trigeminal nerve. 4, 3
• Palpation of temporal arteries for tenderness, nodularity, or absent pulse. 2

Order imaging based on clinical findings:

• MRI with contrast for any suspected neurological cause or if dental examination is normal but pain persists. 2, 4
• Ultrasound if salivary gland pathology is suspected. 1

Management Algorithm

If dental pathology is identified: Treat the specific dental condition. 1

If TMD is diagnosed:

• Address modifiable risk factors including poor oral health, ill-fitting dentures, uncontrolled diabetes, and tobacco use. 5
• Initiate cognitive behavioral therapy (CBT) early to address psychological components that exacerbate symptoms and improve coping strategies. 4
• Consider NSAIDs and muscle relaxation techniques. 6

If neuropathic pain is diagnosed:

• Gabapentin is the first-line agent, starting at 300mg at bedtime and titrating up to 900-3600mg daily in divided doses. 4
• Alternative medications include amitriptyline, topical lidocaine, and alpha lipoic acid if gabapentin fails or is poorly tolerated. 4, 6

Critical Pitfall to Avoid

The most dangerous error is delayed recognition of giant cell arteritis in patients over 50 years old with jaw claudication, which can result in irreversible vision loss—corticosteroids must be started immediately based on clinical suspicion without waiting for biopsy confirmation. 1, 2