Jaw Pain/Swelling

• 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

Treatment

• Dental or periodontal pathology, oral lesions, salivary pathology, and oral neoplasms require specialized treatment by dental specialist or oral surgeon
• TMJ: Initial treatment includes pain management, bite block (night guard), cold/warm compresses, intra-articular steroid/lidocaine injections, and avoidance of jaw clenching and gum chewing
• Temporal arteritis: Temporal artery biopsy and high- dose steroids
• Headache: Pain relievers, stress reduction, migraine-specific therapy (e.g., triptans), and manipulation
• Neuralgia and neuropathies may be treated with NSAIDs, anticonvulsants (e.g., valproic acid, gabapentin), medical pain management and/or directed therapy (e.g., nerve block)
• Treat underlying systemic etiologies and behavioral disease as necessary

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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