What should I do about lower right side jaw pain?

Lower Right Side Jaw Pain: Evaluation and Management

Start with a dental evaluation to rule out odontogenic causes, then proceed systematically through temporomandibular disorders (TMD), neuropathic conditions, and life-threatening causes based on specific clinical features. 1

Immediate Red Flags Requiring Urgent Evaluation

Before proceeding with routine management, you must exclude these emergent conditions:

• Age >50 with jaw claudication (pain worsening with chewing), temporal headache, scalp tenderness, visual changes, fever, or malaise suggests giant cell arteritis—obtain immediate ESR and CRP, start high-dose prednisone (minimum 40 mg daily) without delay to prevent permanent vision loss, and arrange temporal artery biopsy within 2 weeks 2

• Sharp, electric shock-like pain lasting seconds to minutes, triggered by light touch, washing, eating, or brushing teeth indicates trigeminal neuralgia—obtain MRI to exclude tumors or multiple sclerosis, start anticonvulsants as first-line treatment 1, 2

• Progressive swelling, exposed bone, or fistulas suggest osteonecrosis or malignancy—refer urgently to oral/maxillofacial surgery 3, 4

First Step: Dental Causes (Most Common)

Obtain dental evaluation first because chronic dental infections frequently mimic TMD and other facial pain syndromes 5:

• Look for localized tooth tenderness, percussion sensitivity, or thermal sensitivity 5
• Consider panoramic radiography if dental pathology suspected 3
• C-reactive protein can detect latent dental infection when clinical findings are subtle 5
• CT scan may reveal insidious chronic infection not apparent on plain films 5

Common pitfall: Treating presumed TMD for weeks while missing underlying dental abscess or periapical pathology 5

Second Step: Temporomandibular Disorders (Most Common Non-Dental Cause)

TMD affects 5-12% of the population and is by far the most common non-dental cause of jaw pain 1, 4:

Clinical Features Suggesting TMD:

• Dull, aching pain in jaw joint area, worsening with chewing or jaw movement 1, 4
• Joint sounds (clicking, popping, crepitus) 1
• Limited mouth opening or deviation during opening 4
• Bilateral TMJ tenderness on palpation 4
• Pain often associated with stress, teeth grinding, or jaw clenching 6

Initial Conservative Management (Try for 4-6 Weeks):

Education and self-management are the cornerstone—improved self-efficacy leads to fewer symptoms 1, 3:

• Jaw rest: avoid wide mouth opening, hard/chewy foods, gum chewing 3, 4
• Soft diet during acute flares 3
• Simple analgesics: NSAIDs or acetaminophen for pain control 3
• Basic jaw exercises and self-massage 3
• Heat or ice application to affected area 1

When to Refer (After 4-6 Weeks of Conservative Management):

Refer to oral/maxillofacial surgeon or dentist specializing in TMD if 3:

• Pain persists despite conservative measures
• Progressive limitation in jaw function
• Significant impact on quality of life (difficulty eating, speaking)
• Diagnostic uncertainty
• Progressive dentofacial deformity or mandibular asymmetry

Advanced TMD Management:

• Hard full coverage stabilization splints may have some efficacy, but education may be more beneficial long-term 1
• Cognitive behavioral therapy has strong evidence for chronic TMD pain 1, 4
• Physiotherapy with jaw mobilization and manual trigger point therapy provides substantial pain reduction 1, 4
• Insufficient evidence for low-level laser therapy 1
• Botulinum toxin showed no benefit in RCT 1

Critical point: Up to 30% of acute TMD cases progress to chronic pain—address psychological factors (depression, catastrophizing) early as they reduce treatment success 3, 4

Third Step: Post-Traumatic or Neuropathic Pain

If there is history of dental procedures (root canal, extraction, implants) or facial trauma:

Post-Traumatic Trigeminal Neuropathic Pain:

• Continuous burning, tingling, or sharp pain at site of previous injury 1
• May develop within 3-6 months of trauma 1
• History of poor analgesia during the procedure is common 1
• Allodynia or other sensory changes on examination 1
• Management: Neuropathic pain medications (gabapentin, pregabalin, tricyclic antidepressants), though high failure rate 1

Atypical Odontalgia (Persistent Dentoalveolar Pain):

• Continuous aching, dull, throbbing pain localized to tooth or tooth-bearing area 1
• No identifiable dental pathology on examination or radiographs 1
• Mild to moderate severity 1
• Management: Cognitive behavioral therapy, neuropathic pain medications 1

Fourth Step: Other Neuropathic Causes

Post-Herpetic Neuralgia:

• History of herpes zoster rash in trigeminal distribution 1
• Continuous burning, tingling, itchy, tender pain 1
• Allodynia and hyperalgesia on examination 1
• Management: Follow neuropathic pain guidelines 1

Glossopharyngeal Neuralgia:

• Deep pain in ear and/or back of tongue, tonsils, neck 1
• Triggered by swallowing, coughing, or touching ear 1, 2
• Can rarely provoke syncope 2
• Management: Anticonvulsants, surgery for refractory cases 1

Fifth Step: Salivary Gland Pathology

Salivary Stone (Sialolithiasis):

• Intermittent dull, aching pain in submandibular area 1, 2
• Pain characteristically occurs just before eating 2
• Tender salivary gland on bimanual palpation 1
• Stone may be palpable in duct 1
• Slow or absent salivary flow from affected duct 1
• Diagnosis: Ultrasound imaging 1, 2
• Management: Refer to oral/maxillofacial surgery for removal 1, 2

Multidisciplinary Referral for Complex or Refractory Cases

For patients failing routine management after 3-6 months, refer to multidisciplinary TMJ clinic which provides superior outcomes in pain scores, mouth opening, and quality of life 3:

The team should include 3:

• Oral and maxillofacial surgeon
• Oral medicine specialist
• Physiotherapist with TMJ expertise
• Maxillofacial prosthetist
• Psychiatrist or psychologist

Common pitfall: Sequential single-specialty consultations rather than coordinated multidisciplinary care leads to worse outcomes for chronic facial pain 3

Specific Physical Examination Components

Perform standardized orofacial examination 1, 3:

• Palpate TMJ bilaterally for tenderness 4
• Measure maximum mouth opening (normal >40mm) 1
• Assess for deviation during opening 1, 4
• Check for joint sounds during opening/closing 1
• Palpate masseter and temporalis muscles for tenderness 6
• Light touch testing in all three trigeminal divisions to identify trigger zones or sensory abnormalities 1, 2
• Examine temporal arteries for tenderness, nodularity, or absent pulse if age >50 2
• Intraoral examination for dental pathology, exposed bone, or mucosal lesions 5

Treatment Algorithm Summary

1. Exclude emergencies (giant cell arteritis, trigeminal neuralgia, infection, malignancy) 2, 5
2. Rule out dental causes with examination and imaging 5
3. Initiate conservative TMD management for 4-6 weeks 3
4. Refer to oral/maxillofacial surgeon or TMD specialist if no improvement 3
5. Consider neuropathic pain management if post-traumatic or burning/electric quality 1
6. Multidisciplinary referral for refractory cases after 3-6 months 3