What are the possible causes of right cheek (buccal/masseter) muscle pain?

Right Cheek Muscle Pain: Causes and Diagnostic Approach

The most common cause of right cheek (buccal/masseter) muscle pain is temporomandibular disorder (TMD), specifically myofascial pain affecting the muscles of mastication, which accounts for the majority of non-dental chronic facial pain cases. 1

Primary Musculoskeletal Causes

Temporomandibular Disorders (TMD)

• TMD affects 5-12% of the population with peak incidence at ages 20-40 years, making it the leading cause of chronic facial pain in the cheek region. 1, 2
• The masseter muscle (the primary chewing muscle in the cheek) is involved in 68-70% of TMD cases with myofascial pain. 3
• Pain characteristics include:
  • Dull, aching quality that may worsen with chewing, talking, or jaw movement 1
  • Tenderness on palpation of the masseter muscle 1
  • May be associated with jaw clicking, limited opening, or crepitus 1
  • Often bilateral but can present unilaterally 1

Myofascial Pain with Trigger Points

• Myofascial pain syndromes are extremely common but frequently underdiagnosed in the maxillofacial region, characterized by hypersensitive trigger points in the masseter and other facial muscles. 4, 5
• Trigger points produce local and referred pain patterns that can extend beyond the immediate muscle area 4, 5
• Patients with myofascial pain often report pain in multiple body regions (44 out of 50 patients in one study reported pain in at least four different body areas) 3

Dental and Oral Causes

• Dental pathology must be excluded first, as tooth-related pain can radiate to the cheek area and mimic muscle pain. 1
• Specific dental causes include:
  • Dental abscess or infection affecting upper molars or premolars 1
  • Post-extraction complications 1
  • Bruxism (teeth grinding) causing secondary muscle overload 1

Salivary Gland Disorders

• Submandibular or parotid gland pathology can present as cheek pain, particularly if there is duct obstruction or infection. 1, 2
• Salivary stones characteristically cause intermittent pain that occurs just before eating, with tender gland on palpation 1, 2
• Ultrasound imaging is the preferred diagnostic modality for salivary gland evaluation 2

Neuropathic Causes

Post-Traumatic Trigeminal Neuropathic Pain

• Dental procedures (extractions, root canals, implants) or facial trauma can cause neuropathic pain in the trigeminal nerve distribution, including the cheek area. 1
• Pain quality is typically burning, tingling, or sharp rather than dull/aching 1
• Symptoms often begin within 3-6 months of the inciting trauma 1
• May be associated with allodynia or altered sensation 1

Trigeminal Neuralgia

• Presents with paroxysmal attacks of sharp, electric shock-like pain lasting seconds to minutes 1, 2
• Triggered by light touch, eating, or brushing teeth with mandatory refractory periods between attacks 1, 2
• This is distinctly different from continuous muscle pain and should not be confused with TMD. 1, 2

Critical Red Flags Requiring Urgent Evaluation

Giant Cell Arteritis (Age >50 Years)

• Jaw claudication (pain with chewing that improves with rest), temporal region tenderness, scalp tenderness, visual disturbances, or fever require immediate ESR and CRP testing. 2, 6
• This condition can cause irreversible vision loss if untreated and requires high-dose corticosteroids urgently 2, 6
• Must be distinguished from TMD, especially in patients over 50 years 1, 2

Malignancy

• Progressive unilateral pain with a palpable mass, non-healing ulceration, or induration requires urgent imaging and referral within 1-2 weeks. 2, 7
• Risk factors include tobacco/alcohol use and age over 40 years 7

Diagnostic Approach

History Taking Priorities

• Pain timing: continuous versus intermittent, relationship to jaw movement, chewing, or eating 1
• Pain quality: dull/aching (suggests muscle) versus sharp/electric (suggests nerve) versus intermittent before meals (suggests salivary gland) 1
• Aggravating factors: prolonged chewing, clenching, bruxism, stress, cold weather 1
• Associated symptoms: jaw clicking, limited opening, dental symptoms, altered sensation, dry mouth 1
• Comorbidities: depression, catastrophizing, fibromyalgia, chronic widespread pain, headaches 1, 2

Physical Examination Essentials

• Palpate the masseter muscle bilaterally for tenderness, trigger points, and hypertrophy 1
• Assess temporomandibular joint for clicking, crepitus, and range of motion 1
• Examine teeth for decay, mobility, wear facets indicating bruxism 1
• Bimanual palpation of salivary glands and assessment of salivary flow from ducts 1, 7
• Check for palpable masses, lymphadenopathy, or skin lesions 1, 7

When to Image

• Dental X-rays if dental pathology suspected 1
• Ultrasound for salivary gland disorders 2
• MRI brain with contrast if progressive symptoms, additional neurologic signs, or concern for structural lesion 6
• ESR/CRP if age >50 with jaw claudication or temporal symptoms 2, 6

Initial Management for TMD-Related Muscle Pain

Early diagnosis with reassurance and education is often the most effective initial approach, as improved self-efficacy leads to fewer symptoms. 1, 2

• Patient education about the benign nature of TMD and self-management strategies 1
• Simple physiotherapy including jaw stretching exercises and postural correction 1, 5
• Hard full-coverage stabilization splints worn at night may provide benefit for reducing muscle overactivity 1, 2
• Cognitive behavioral therapy is effective, particularly when psychological factors like depression or catastrophizing are present 1, 2
• Trigger point injections for myofascial pain with identified trigger points 5

Common Pitfalls to Avoid

• Do not assume all cheek pain is dental—TMD is far more common than appreciated 1, 4
• Do not miss giant cell arteritis in patients over 50 years with new-onset jaw pain 2, 6
• Do not overlook psychological comorbidities (depression, catastrophizing) that significantly increase chronicity risk 1, 2
• Do not use soft splints or appliances that don't account for occlusion, as these can cause tooth movement and malocclusion 1
• Do not pursue aggressive interventions before trying conservative management with education and physiotherapy 1