What is the best course of treatment for jaw pain associated with poor dentition?

Management of Jaw Pain with Poor Dentition

The first priority is urgent dental evaluation to address the underlying dental pathology causing the pain, as acute dental causes are the most common source of jaw pain and are effectively managed by dentists. 1

Immediate Assessment and Red Flags

Before proceeding with treatment, rule out serious conditions that require urgent intervention:

• Giant cell arteritis must be excluded, especially in patients over 50 years old, as it can mimic temporomandibular disorders 1
• Cancer can present as progressive neuropathic pain and must be considered in the differential 1
• Acute dental infection or abscess requires immediate dental intervention 1

Primary Treatment Pathway

Step 1: Dental Correction (0-4 weeks)

Poor dentition must be addressed first, as dental pathology is the most common acute cause of jaw pain and cannot be effectively managed without correcting the underlying structural problems 1. This includes:

• Treatment of dental decay, periodontal disease, and gingivitis 1
• Extraction or restoration of damaged teeth 1
• Management of malocclusion if present 1

Step 2: Conservative Management (Concurrent with Dental Treatment)

While dental issues are being addressed, initiate conservative measures:

First-line strongly recommended interventions:

• Supervised jaw exercises and stretching provide approximately 1.5 times the minimally important difference in pain reduction 2, 3
• Manual trigger point therapy provides one of the largest reductions in pain severity, approaching twice the minimally important difference 2, 3
• Patient education about avoiding aggravating activities, maintaining a soft diet, and applying heat/cold therapy 2, 3
• NSAIDs for pain relief and inflammation reduction 3

Step 3: Second-Line Interventions (4-12 weeks if inadequate response)

If pain persists after dental correction and initial conservative management:

• Cognitive behavioral therapy (CBT) with or without biofeedback provides substantial pain reduction 2, 3
• Manipulation techniques for joint realignment may benefit some patients 2, 3
• Acupuncture shows moderate evidence of effectiveness 2, 3
• Physical therapy with jaw mobilization (therapist-assisted manual techniques) 3, 4

Pharmacological Management

NSAIDs are first-line medications for pain and inflammation 3. Additional options include:

• Muscle relaxants may help overcome muscle spasm when other approaches fail 3
• Neuromodulatory medications (amitriptyline, gabapentin) can be considered for chronic refractory pain 3
• Never combine NSAIDs with opioids due to increased risks without clear additional benefits 2, 3

Critical Interventions to Avoid

Occlusal splints are conditionally recommended against despite their widespread use, as evidence for effectiveness is limited 2, 3. They may only be considered specifically for patients with documented bruxism 5, 3.

Strongly avoid these interventions:

• Irreversible procedures like permanent alterations to dentition 2, 5, 3
• Discectomy (surgical disc removal) 2, 5, 3
• Proceeding to invasive procedures before exhausting conservative options for at least 3-6 months 3

Referral Pathway

Refer to a dentist first for evaluation and management of poor dentition 1. If pain persists after dental correction:

• Physical therapist with TMJ expertise for manual trigger point therapy and jaw mobilization 3, 4
• Multidisciplinary team (oral and maxillofacial surgeons, orofacial pain specialists, physical therapists) if conservative treatments fail after 3-6 months 3, 6
• Pain management specialist for intractable pain unresponsive to dental interventions 3

Common Pitfalls

• Never neglect the underlying dental pathology - treating TMJ symptoms without addressing poor dentition will result in treatment failure 1
• Do not rely solely on occlusal splints despite their popularity in dental practice 2, 3
• Avoid jumping to invasive procedures before exhausting at least 3-6 months of conservative treatment 3
• Do not overlook psychological comorbidities including depression and chronic pain elsewhere, which require a biopsychosocial approach 1