What are the causes and treatments of bad right side lower jaw pain?

Right Lower Jaw Pain: Causes and Management

Immediate Life-Threatening Causes to Rule Out

If you are over 50 years old with jaw pain, especially if accompanied by headache, vision changes, or systemic symptoms, you need immediate evaluation for giant cell arteritis—a condition that can cause permanent blindness if not treated urgently. 1

Giant Cell Arteritis (Critical Emergency)

• Presents with jaw claudication (pain with chewing that improves with rest), temporal headache, scalp tenderness, visual disturbances, fever, and malaise 1
• Requires immediate ESR and CRP testing—both will be markedly elevated 1
• Treatment must not be delayed: start high-dose corticosteroids (minimum 40 mg prednisone daily) immediately, even before biopsy confirmation 1
• Vision loss from ophthalmic artery involvement is devastating and preventable with prompt treatment 1

Most Common Causes of Unilateral Lower Jaw Pain

Temporomandibular Disorders (TMD)

TMD is the most common non-dental cause of facial pain, affecting 5-12% of the population, and should be your primary consideration for unilateral jaw pain. 2

Clinical Features:

• Pain localized to the TMJ area that worsens with jaw function (chewing, speaking) 2
• Joint tenderness on palpation, limited jaw opening, clicking or popping sounds 2
• May be unilateral or bilateral 2
• Up to 30% of acute TMD cases progress to chronic pain 2

Evidence-Based Treatment Approach:

Cognitive behavioral therapy (CBT) combined with relaxation therapy or biofeedback provides the greatest pain relief for chronic TMD pain. 3, 2

• First-line treatments (conditional recommendations): 3

  • Therapist-assisted jaw mobilization and manual trigger point therapy 2
  • Removable occlusal splints 3
  • Physical therapy and jaw exercises 3
  • Patient education about self-management 2
  • NSAIDs with or without steroids 3

• Additional options with uncertain benefits: 3

  • Transcutaneous electrical nerve stimulation
  • Low-level laser therapy
  • Trigger point injections
  • Botulinum toxin injection
  • Gabapentin for neuropathic component

• Strongly recommended AGAINST: 3

  • Irreversible oral splints (can cause permanent harm)
  • Discectomy
  • NSAIDs combined with opioids

Trigeminal Neuralgia

Trigeminal neuralgia causes paroxysmal attacks of sharp, electric shock-like pain in the jaw, triggered by light touch, eating, or brushing teeth, with pain-free intervals between attacks. 1

Diagnostic Features:

• Unilateral, shooting pain confined to trigeminal nerve distribution 1
• Triggered by specific activities: washing face, cold wind, chewing, brushing teeth 1
• Refractory period between attacks (pain-free intervals) 1
• Light touch testing can identify trigger zones 1

Management:

• MRI with contrast is mandatory to exclude tumors, multiple sclerosis, or neurovascular compression 1
• First-line treatment: anticonvulsants (carbamazepine, with phenytoin or baclofen as alternatives) 4
• Surgery reserved for refractory cases 1

Dental and Oral Pathology

Dental Causes:

• Most dental pain is from caries or periodontal disease 4
• Acute pericoronitis (especially mandibular third molars) responds to irrigation and antimicrobial therapy 4
• Critical caveat: Patients with trigeminal neuralgia sometimes have teeth unnecessarily extracted—meticulous dental examination is essential before diagnosing idiopathic trigeminal neuralgia 5

Salivary Gland Disorders:

• Salivary stones cause intermittent pain characteristically occurring just before eating 1, 6
• Bimanual palpation may reveal the stone with slow or absent salivary flow from affected duct 1
• Ultrasound imaging for diagnosis, with referral to oral/maxillofacial surgery for stone removal 1, 6
• Salivary gland tumors (especially malignant with perineural invasion) can cause intermittent pain 1

Medication-Related Osteonecrosis of the Jaw (MRONJ)

If you have a history of bisphosphonate use or radiation therapy, monitor for exposed mandibular bone, jaw swelling, or fistulas that probe to bone 3, 2, 6

Management Approach:

• Conservative treatment initially: antimicrobial mouth rinses (chlorhexidine gluconate or povidone-iodine twice daily) 3, 6
• Systemic antibiotics only when clinically indicated 3
• Avoid aggressive debridement unless conservative measures fail 6
• Referral to oral/maxillofacial surgeon for evaluation 6

Red Flags Requiring Urgent Specialist Referral

Refer within 1-2 weeks maximum if any of the following are present: 6

• Palpable mass in jaw or neck (concern for malignancy) 6
• Exposed bone or non-healing ulceration 3, 6
• Age >40 with unilateral pain, induration, or non-healing lesions, especially with tobacco/alcohol use 6
• Persistent pain after dental procedures without obvious cause 7
• Visual disturbances or neurological symptoms 1

Diagnostic Workup Algorithm

Initial Evaluation:

1. Age >50 with jaw claudication or systemic symptoms: Immediate ESR and CRP 1
2. Palpate temporal arteries for tenderness, nodularity, or absent pulse 1
3. TMJ examination: Bilateral palpation for tenderness, assess jaw opening range and deviation 2
4. Cranial nerve examination: Light touch testing in all three trigeminal divisions to identify trigger zones 1
5. Bimanual palpation of floor of mouth and submandibular areas for masses or stones 6

Imaging:

• MRI with contrast: Gold standard for TMJ synovitis, soft tissue evaluation, and suspected neurological causes 3, 1, 2
• CT or CBCT: Preferred for evaluating bone lesions associated with chronic synovitis 2
• Ultrasound: Useful for salivary stone diagnosis 1

Atypical Odontalgia and Neuropathic Pain

If pain persists after multiple dental procedures without relief, and no local source of pathology can be found, consider a focal neuropathic pain disorder. 7

Diagnostic Criteria:

• Unrelenting pain in teeth, gingival, or alveolar tissues despite multiple irreversible procedures 7
• Up to one-third of chronic facial pain clinic patients have undergone prior unsuccessful dental procedures 7
• Majority are women over age 30 with pain in posterior teeth/alveolar arch 7

Required Diagnostic Procedures: 7

• Cold testing of involved teeth for pulpal vitality
• Periapical radiograph examining teeth for apical changes
• Panoramic radiograph for other maxillofacial disease
• Thorough head and neck examination
• Cranial nerve examination including anesthetic testing
• MRI imaging in selected cases
• Direct microscopic examination for incomplete tooth fracture

Treatment:

• Pharmacologic medications that suppress nerve activity: gabapentin, tricyclics, topical anesthetics 7
• Important prognostic information: Once dental treatment has failed and pain persists, less than 25% will have complete pain relief with treatment 7

Critical Pitfalls to Avoid

• Never perform irreversible dental procedures (extractions, implants, aggressive surgery) for atypical facial pain without definitive diagnosis—this exacerbates the condition 4
• Do not use irreversible oral splints for TMD—they are associated with important harms 3
• Do not delay corticosteroids while awaiting temporal artery biopsy in suspected giant cell arteritis 1
• Avoid intraarticular glucocorticoid injections as first-line TMJ treatment in skeletally immature patients due to risk of growth disturbance 3