What is the differential diagnosis (ddx) for jaw pain in a 60-year-old female?

Differential Diagnosis for Jaw Pain in a 60-Year-Old Female

In a 60-year-old female with jaw pain, the differential diagnosis must prioritize temporomandibular disorders (TMD) as the most common non-dental cause, while urgently excluding giant cell arteritis—a critical red flag in patients over 50 that can cause permanent vision loss if missed. 1

Critical Red Flags to Exclude First

Giant Cell Arteritis (GCA)

• Must be distinguished from TMD in all patients over 50 years old with temporal or jaw pain 1, 2
• Presents with jaw claudication (pain with chewing), temporal headache, visual symptoms, and arthralgias 3
• Can cause devastating bilateral vision loss if not treated emergently with corticosteroids 3
• Requires immediate ESR/CRP testing and temporal artery biopsy 1

Malignancy

• Cancer can present as progressive neuropathic jaw pain 1, 4
• Consider primary oral cancer or metastatic disease in this age group 1
• Requires thorough intraoral examination for soft tissue lesions and imaging (CT/MRI) if suspected 1

Cardiac Ischemia

• Myocardial ischemia can present solely as TMJ/jaw pain, particularly during physical exertion 5
• Consider if pain occurs with activity, especially in patients with cardiac risk factors 5
• Requires immediate cardiac workup if suspected 5

Common Differential Diagnoses

Temporomandibular Disorders (TMD)

• Most common non-dental cause of chronic jaw pain 1
• Typically musculoskeletal, involving muscles of mastication unilaterally or bilaterally 1
• Key features to assess: 1
  • Clenching/bruxing habits
  • Jaw clicking, locking, or crepitus
  • Tenderness of masticatory muscles on palpation
  • Trigger points in head/neck muscles
  • Wear facets on teeth indicating bruxism
  • Limited jaw opening or deviation
• Often associated with other chronic pain conditions, fibromyalgia, headaches, and mood disorders 1

Dental and Oral Causes

• Acute dental pain is the most common cause overall and typically unilateral 1
• Specific conditions to evaluate: 1
  • Dental caries, pulpitis, or periapical abscess
  • Periodontal disease
  • Cracked tooth syndrome
  • Chronic dental infection (can mimic TMD) 6
• Requires good lighting and thorough intraoral examination of teeth, gingiva, and oral mucosa 1

Maxillary Sinusitis

• Can occur after dental procedures on upper premolars/molars or from dental infection 1
• Presents with facial pressure, nasal discharge, and pain aggravated by bending forward 1
• May develop oral-antral fistula requiring surgical closure 1

Salivary Gland Disorders

• Tumors, duct blockage, or infection (sialadenitis) 1
• Palpate for gland swelling and tenderness 1
• Best investigated with ultrasound 1

Neuropathic Pain Syndromes

• Trigeminal neuralgia: Unilateral, episodic, severe electric shock-like pain provoked by light touch 1
• Post-traumatic neuropathic pain: Following dental procedures or facial trauma 1
• Persistent idiopathic facial pain (PIFP): Continuous pain without clear cause, often with history of other chronic pains and mood disorders 7
• Burning mouth syndrome: Neuropathic pain occurring principally in peri-menopausal women, often misattributed to psychological causes 1

Temporomandibular Joint Disorders

• Internal derangement (disc displacement with/without reduction) 1
• Inflammatory disorders (synovitis, capsulitis) 1
• Arthritis, ankylosis, or condylar abnormalities 1

Essential History Components

Obtain detailed pain characteristics: 1

• Timing: Onset, duration, continuous vs. episodic pattern
• Location: Unilateral vs. bilateral, radiation pattern
• Quality: Sharp, dull, burning, electric shock-like, throbbing
• Severity: Impact on function and quality of life
• Aggravating factors: Chewing, jaw movement, touching face, hot/cold foods, stress, physical activity
• Relieving factors: Rest, medications, jaw positioning

Associated symptoms to identify: 1

• Jaw clicking, locking, or limited opening
• Bruxism or clenching habits
• Altered sensation or numbness
• Visual changes, temporal headache (GCA red flag)
• Nasal/sinus symptoms
• Other chronic pain conditions
• Impact on sleep, mood, concentration

Physical Examination Approach

Extraoral examination: 1

• Visual inspection for swelling, color changes, asymmetry
• Palpate temporal arteries (tenderness suggests GCA)
• Assess masticatory and neck muscles for tenderness, trigger points, hypertrophy
• Evaluate TMJ movement, crepitus, clicking
• Cranial nerve examination

Intraoral examination: 1

• Inspect teeth for decay, mobility, wear facets
• Examine occlusion and jaw opening (normal >40mm)
• Assess oral mucosa for lesions
• Palpate for dental tenderness

Diagnostic Testing Strategy

Laboratory tests: 1

• ESR and CRP if GCA suspected (mandatory in patients >50 with temporal/jaw pain)
• Consider autoimmune workup if Sjögren's syndrome suspected

Imaging: 1

• Dental X-rays or panoramic radiograph for dental causes
• Ultrasound for salivary gland pathology
• MRI for TMJ soft tissue evaluation (gold standard for disc/ligament assessment) 1
• CT or CBCT for bony TMJ pathology (gold standard for bone lesions) 1
• Consider cardiac workup if ischemia suspected

Pain assessment tools: 1, 2

• Brief Pain Inventory, McGill Pain Questionnaire, or Beck Depression Inventory for comprehensive evaluation

Common Pitfalls to Avoid

• Failing to screen for GCA in patients over 50 with jaw or temporal pain—this can result in irreversible vision loss 1, 2, 3
• Assuming all jaw pain is TMD without thorough dental examination—chronic dental infections can mimic TMD 6
• Missing cardiac ischemia presenting as isolated jaw pain during exertion 5
• Overreliance on imaging without appropriate clinical correlation 2
• Not considering the biopsychosocial context—TMD and chronic facial pain often coexist with depression and other chronic pain conditions 1