Routine diagnostic studies include a CBC, sedimentation rate, chemistry panel, arthritis panel, and an x-ray of the teeth and jaw. X-ray of the sinuses may be helpful. At this point referral to a dentist or oral surgeon should be made if there is still diagnostic difficulty. He may order an MRI of the temporomandibular joint, which is the procedure of choice in evaluating this joint. If all tests are negative or equivocal, perhaps a psychiatric referral is in order.
Dental or periodontal pathology
–Associated with temperature sensitivity and pain upon biting
- TMJ disorders
–Associated with unilateral or bilateral achy pain and diffuse tenderness of the masseter and temporalis muscles
–Exaggerated by jaw use
–Joint may be tender to palpation
–“Clicking” sounds are often present
–More common in females age <50
-
Giant cell (temporal) arteritis
–Unilateral pain in older patients
–Headache, jaw claudication, and vision loss
-
Mucosal lesions (buccal mucosa, hard and soft
palate, floor of mouth, or oropharynx)
–Aphthous ulcers
–Herpes simplex or coxsackievirus B
–Cancer
–Tongue or lip lesions
-
Paranasal sinus pathology
–Most common pathology is maxillary
sinusitis secondary to viral URI
–Pain is often referred to the upper molars
-
Salivary gland pathology, including inflammation (e.g., parotiditis), ductal stone, or neoplasm
-
Headache with radiation to the jaw
-
Referred pain from cardiac, cervical spine, pulmonary, or throat disease
-
Neuralgias (e.g., trigeminal, glossopharyngeal)
-
Neuropathies
–Systemic neuropathies (e.g., HIV, diabetes)
–Dental/alveolar neuropathies, usually
subsequent to extrinsic trauma (e.g., blow to face, dental surgical intervention)
-
Behavioral disorders
-
Primary neoplasms of the maxilla, mandible, or major salivary gland
-
Metastases to mandible, maxilla, or TMJ
-
Herpes zoster or post-herpetic neuralgia
-
Fibromyalgia
-
Rheumatologic disease (e.g., Sjögren's syndrome)
-
Systemic arthritis (e.g., rheumatoid arthritis)
Workup and Diagnosis
- History and physical examination, with focus on the head and neck
–Review onset, character, and pattern of pain; past medical and surgical history; associated symptoms (e.g., weight loss, sinus pain, skin complaints); and complete review of systems, including screening for local and systemic pathology and a cervical evaluation for muscle, neural, or skeletal referred pain
–Perform a thorough oral exam of the buccal mucosa, lips, hard palate, soft palate, posterior pharynx, floor of mouth, and the top, sides, and undersurface of the tongue
–Perform a head, neck, ear, nose, cardiac, pulmonary, and lymphatic exam
–Suspect dental pathology until proven otherwise
-
Initial workup is aimed at assessing the mouth and jaw for dental, periodontal, or TMJ disorders
-
Appropriate laboratory studies are based upon the suspected diagnosis (e.g., CBC and ESR for temporal arteritis)
-
Imaging studies may include Panorex films, sinus X-ray, CT scan, and/or MRI
-
Therapeutic trial of medications (e.g., NSAIDs)
-
Temporal artery biopsy is indicated if ESR elevated
-
Biopsy any suspicious lesion
-
Referral to a dental or medical specialist may be necessary
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» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Jaw pain:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin the patient history by asking him to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Where on the jaw does he feel pain? Does the pain radiate to other areas? Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints. Also ask about aggravating or alleviating factors.
Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, a headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. (Keep in mind that jaw pain may accompany more characteristic signs and symptoms of life-threatening disorders such as chest pain in a patient with an MI.)
Focus your physical examination on the jaw. Inspect the painful area for redness, and palpate for edema or warmth. Facing the patient directly, look for facial asymmetry indicating swelling. Check the TMJs by placing your fingertips just anterior to the external auditory meatus and asking the patient to open and close, and to thrust out and retract his jaw. Note the presence of crepitus, an abnormal scraping or grinding sensation in the joint. (Clicks heard when the jaw is widely spread apart are normal.) How wide can the patient open his mouth? Less than 1 ⅛" (3 cm) or more than 2⅜" (6 cm) between the upper and lower teeth is abnormal. Next, palpate the parotid area for pain and swelling, and inspect and palpate the oral cavity for lesions, elevation of the tongue, or masses.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Jaw pain:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin the patient history by asking the patient to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Where on the jaw does he feel pain? Does the pain radiate to other areas? Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints. Also ask about aggravating or alleviating factors.
Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. (Keep in mind that jaw pain may accompany more characteristic signs and symptoms of life-threatening disorders, such as chest pain in a patient with an MI.)
Focus your physical examination on the jaw. Inspect the painful area for redness, and palpate for edema or warmth. Facing the patient directly, look for facial asymmetry indicating swelling. Check the TMJs by placing your fingertips just anterior to the external auditory meatus and asking the patient to open and close, and to thrust out and retract his jaw. Note the presence of crepitus, an abnormal scraping or grinding sensation in the joint. (Clicks heard when the jaw is widely spread apart are normal.) How wide can the patient open his mouth? Less than 1 ⅛” (3 cm) or more than 2⅜” (6 cm) between upper and lower teeth is abnormal. Next, palpate the parotid area for pain and swelling, and inspect and palpate the oral cavity for lesions, elevation of the tongue, or masses.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Perirectal abscess and fistula:
Diagnosis
(Handbook of Diseases)
Perirectal abscess is detectable on physical examination:
❑ Perianal abscess is a red, tender, localized, oval swelling close to the anus. Sitting or coughing increases pain, and pus may drain from the abscess. Digital examination reveals no abnormalities.
❑ Ischiorectal abscess involves the entire perianal region on the affected side of the anus. The only symptom of this large erythematous, indurated, tender mass may be pain. It’s tender but may not produce drainage. Digital rectal examination reveals a tender induration bulging into the anal canal.
CLINICAL TIP: A flexible sigmoidoscopy should be performed later on these patients to rule out cancer or inflammatory bowel disease.
❑ Submucous or high intermuscular abscess may produce a dull, aching pain in the rectum, tenderness and, occasionally, induration. Digital examination reveals a smooth swelling of the upper part of the anal canal or lower rectum.
❑ Pelvirectal abscess (rare) produces fever, malaise, and myalgia but no local anal or external rectal signs or pain. Digital examination reveals a tender mass high in the pelvis, perhaps extending into one of the ischiorectal fossae.
If the abscess drains by forming a fistula, the pain usually subsides and the major signs become pruritic drainage and subsequent perianal irritation.
CLINICAL TIP: Pain and discharge are symptoms of fistula development and the closure of the external or secondary opening.
The external opening of a fistula generally appears as a pink or red, elevated, discharging sinus or ulcer on the skin near the anus. Depending on the infection’s severity, the patient may have chills, fever, nausea, vomiting, and malaise. Digital rectal examination may reveal a palpable indurated tract and a drop or two of pus on palpation. The internal opening may be palpated as a depression or ulcer in the midline anteriorly or at the dentate line posteriorly. To identify an internal opening, an examination under anesthesia should be performed.
Flexible sigmoidoscopy, barium studies, and colonoscopy should be performed to rule out underlying conditions.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Jaw pain:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Begin the patient history by asking the patient to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Where on the jaw does he feel pain? Does the pain radiate to other areas? Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints. Also ask about aggravating or alleviating factors.
Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. (Keep in mind that jaw pain may accompany more characteristic signs and symptoms of life-threatening disorders, such as chest pain in a patient with an MI.)
Physical examination
Focus your physical examination on the jaw. Inspect the painful area for redness, and palpate for edema or warmth. Facing the patient directly, look for facial asymmetry indicating swelling. Check the TMJs by placing your fingertips just anterior to the external auditory meatus and asking the patient to open and close, and to thrust out and retract his jaw. Note the presence of crepitus, an abnormal scraping or grinding sensation in the joint. (Clicks heard when the jaw is widely spread apart are normal.) How wide can the patient open his mouth ? Less than 1⅛" (3 cm) or more than 2⅜" (6 cm) between upper and lower teeth is abnormal. Next, palpate the parotid area for pain and swelling, and inspect and palpate the oral cavity for lesions, elevation of the tongue, or masses.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Jaw pain:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the patient history by asking the patient to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Did it arise suddenly or gradually? Where on the jaw does he feel pain? Does the pain radiate to other areas?
Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints.
Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. Also ask about aggravating or alleviating factors.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Jaw pain:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin the patient history by asking him to describe the pain's character, intensity, and frequency. When did he first notice the jaw pain? Where on the jaw does he feel pain? Does the pain radiate to other areas? Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints. Also ask about aggravating or alleviating factors.
Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, a headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. (Keep in mind that jaw pain may accompany more characteristic signs and symptoms of life-threatening disorders such as chest pain in a patient with an MI.)
Focus your physical examination on the jaw. Inspect the painful area for redness, and palpate for edema or warmth. Facing the patient directly, look for facial asymmetry indicating swelling. Check the TMJs by placing your fingertips just anterior to the external auditory meatus and asking the patient to open and close, and to thrust out and retract his jaw. Note the presence of crepitus, an abnormal scraping or grinding sensation in the joint. (Clicks heard when the jaw is widely spread apart are normal.) How wide can the patient open his mouth? Less than 1 1⁄89 (3 cm) or more than 23⁄89 (6 cm) between the upper and lower teeth is abnormal. Next, palpate the parotid area for pain and swelling, and inspect and palpate the oral cavity for lesions, elevation of the tongue, or masses.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Sepsis:
Sepsis - DIAGNOSIS
(The 5-Minute Pediatric Consult)
Have a high suspicion for sepsis because presenting signs of fever and tachycardia are nonspecific. Hypotension is not a sensitive sign of septic shock.
» READ BOOK EXCERPT ONLINE »
Source: The 5-Minute Pediatric Consult, 2008
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