What is the primary care approach for a patient with unilateral jaw pain and a palpable lump on their jaw/neck, which started before receiving a dental crown on the contralateral side?

Primary Care Approach to Unilateral Jaw Pain with Palpable Neck/Jaw Mass

This patient requires urgent referral to an oral and maxillofacial surgeon or ENT specialist for comprehensive evaluation, as the combination of unilateral jaw pain and a palpable mass raises concern for malignancy, salivary gland pathology, or other serious conditions that demand specialist assessment and possible biopsy. 1

Immediate Assessment in Primary Care

Critical History Elements

• Age and risk factors: Patients over 40 years with unilateral pain and a mass should be considered at increased risk for malignancy, especially with tobacco or alcohol use 2
• Timeline clarification: The pain preceded the dental crown procedure, making this unlikely to be a simple post-procedural complication 3
• Pain characteristics: Determine if pain is intermittent and occurs before eating (suggesting salivary stone), constant, or related to jaw movement 1
• Associated symptoms: Ask about exposed bone, fistulas, fever, difficulty swallowing, or changes in vision 1, 4

Targeted Physical Examination

• Palpate the mass: Assess size, consistency, mobility, and tenderness; bimanual palpation should be used for floor of mouth and submandibular areas 1
• Examine the skin and oral mucosa: Look for color changes, ulcerations, or non-healing lesions that suggest malignancy 1, 2
• Assess the temporomandibular joint bilaterally: Palpate for tenderness, check jaw opening range, and note any deviation during opening 3
• Complete mucosal surface examination: Inspect the nasopharynx, base of tongue, hypopharynx, and larynx if trained to do so, or refer for this examination 1
• Evaluate salivary glands: Bimanual palpation of submandibular glands and assessment of salivary flow from ducts 1

Differential Diagnosis Priority

High-Risk Conditions Requiring Urgent Referral

• Head and neck malignancy: The location of a neck mass suggests possible metastatic spread; oral cavity primaries typically metastasize to levels I-III, while masses in level IV or supraclavicular regions may indicate primary malignancies below the clavicle 1
• Salivary gland disorders: Stones, tumors, or infection can present with pain and swelling; submandibular stones characteristically cause pain before eating 1
• Medication-related osteonecrosis: If the patient has history of bisphosphonate use or radiation therapy, monitor for exposed mandibular bone 1, 4, 2

Other Considerations

• TMD with synovitis: While TMD is the most common non-dental cause of facial pain (affecting 5-12% of the population), the presence of a palpable mass makes this less likely as the sole diagnosis 3
• Dental abscess or infection: Though the crown was placed on the opposite side, examine for dental pathology including decay, mobile teeth, or periodontal disease 1

Management Algorithm

Step 1: Risk Stratification

• If patient is >40 years with unilateral pain, induration, ulceration, or non-healing lesion: Immediate referral to oral and maxillofacial surgery or ENT for biopsy consideration 2
• If exposed bone is present: Refer urgently to oral surgeon, maxillofacial surgeon, or head/neck surgeon for evaluation of possible osteonecrosis 2
• If salivary stone suspected: Refer to oral and maxillofacial surgery for imaging (ultrasound preferred) and stone removal 1

Step 2: Imaging Considerations

• Do not delay referral for imaging: Physical examination by a specialist with appropriate equipment is essential and cannot be replaced by imaging alone 1
• If imaging is obtained: Ultrasound is best for salivary gland disease; CT or MRI may be indicated based on clinical suspicion, but specialist consultation should guide this 1, 3

Step 3: Symptomatic Management While Awaiting Specialist Evaluation

• Pain control: Provide appropriate analgesics based on pain severity 1
• Antimicrobial mouth rinses: Chlorhexidine gluconate or povidone-iodine solutions twice daily if infection is suspected 1, 4
• Avoid routine antibiotics: Do not prescribe systemic antibiotics unless clear signs of infection are present 1, 4
• Soft diet: Recommend soft foods and avoid excessive jaw movement 1

Critical Pitfalls to Avoid

• Do not attribute symptoms solely to TMD when a palpable mass is present; this combination warrants investigation for more serious pathology 1, 3
• Do not delay referral for dental evaluation alone; the presence of a mass requires specialist assessment that may include biopsy 1, 2
• Do not assume the crown procedure is causative when symptoms preceded the procedure; this temporal relationship suggests an independent process 3
• Do not perform aggressive manipulation of the mass or jaw if osteonecrosis is suspected, as this can worsen the condition 1, 2

Referral Urgency

Refer within 1-2 weeks maximum for evaluation by an oral and maxillofacial surgeon or ENT specialist who can perform complete examination of mucosal surfaces, appropriate imaging, and biopsy if indicated 1, 2. Communication between primary care, the specialist, and the patient's dentist is essential for coordinated care 1.