Facial / Dental / Temporomandibular Pain
Differential Overview
❑ Maxillary sinusitis
❑ Dental infection
❑ Temporomandibular joint dysfunction
❑ Myofascial masseter pain
❑ Migraine
❑ Trigeminal neuralgia
❑ Frontal sinusitis
❑ Ethmoid sinusitis
❑ Sphenoid sinusitis
❑ Parotitis
❑ Parotid calculus
❑ Orbital fracture
❑ Mandibular fracture
❑ Maxillary fracture
❑ Myocardial infarction
❑ Connective tissue disease
❑ Temporal arteritis
❑ Cavernous sinus thrombosis
❑ Glossopharyngeal neuralgia
Diagnostic Approach
The V1 ophthalmic branch of the trigeminal innervates the forehead, cornea (corneal reflex), dorsum of the nose, and anterior cranial dura. The V2 maxillary branch innervates the upper lip, lateral nose, upper cheek, anterior temple, upper jaw and teeth, roof of the mouth, and middle cranial dura. The V3 mandibular branch innervates the lower lip, chin, posterior cheek, external ear, mucosa of the lower mouth, anterior two-thirds of the tongue, and parts of the anterior and middle cranial dura.
Pain provoked by hot, cold, or sweet foods is usually dental in origin. Neuralgia may produce a similar pain, but the pain will have a refractory period after an initial response. Pain increased by chewing suggests trigeminal neuralgia, temporomandibular joint pain, or jaw claudication. Pain increased by swallowing and taste is consistent with glossopharyngeal neuralgia. Objective sensory loss persisting after the pain is an important clue to organic disease.
Epidemiologic studies reveal that temporomandibular joint tenderness is common, occurring in 35% of asymptomatic people, clicking in 25%, crepitus in 8%, and jaw deviation in 15%.
Clinical Findings
Maxillary sinusitis The classic presentation is facial pressure/pain, purulent nasal discharge, and fever. The pain increases when the patient leans forward, and there is tenderness and warmth over the maxilla.
Dental infection Infection is recognized by jaw pain, dental concussion tenderness, heat or cold sensitivity, and gum swelling adjacent to the affected tooth.
Temporomandibular joint dysfunction With temporomandibular joint inflammation, there will be tenderness directly over the joint and pain with opening and closing, but no locking of the jaw. There may be crepitance but no click unless there is associated disc displacement. With disc displacement, there will be limitation of opening and closing of the jaw and deviation away from the affected side.
Myofascial masseter pain There is a dull, aching jaw pain that increases with jaw movement. Jaw opening is limited. The muscles of mastication are tender. Clicks and crepitance are absent. There is usually a history of bruxism or repeated clenching of the jaw.
Migraine Episodic unilateral pain is associated with aura, nausea, and hypersensitivity to light and/or noise.
Trigeminal neuralgia It presents as a paroxysmal intense lancinating or electrical pain in a trigeminal distribution, most frequently in V1 (upper face). It is prompted by thermal or tactile stimuli. There is no objective sensory loss. The tongue may be furred on the affected side. Trigeminal zoster begins acutely with facial dysesthesia and pain, followed by crusting vesicles in a unilateral dermatomal distribution. Postherpetic neuralgia can cause similar pain.
Frontal sinusitis Frontal pain and tenderness are present and often hard to distinguish from a noninfectious frontal tension headache. Pitting edema and severe tenderness over the forehead suggest a contiguous osteomyelitis.
Ethmoid sinusitis Central facial pain and nasal blockage are clues to diagnosis. Complications include orbital cellulitis and, rarely, cavernous sinus thrombosis.
Sphenoid sinusitis Frontal, temporal, or occipital headache is common, and tenderness may occur over the vertex or mastoids.
Parotitis A tender, warm, swollen gland may be palpated at the angle of the jaw. The ampulla of the Stensen duct, opposite the upper second molar, may be inflamed or pus may be expressed. Bilateral parotid enlargement may be seen with mumps, cirrhosis, or bulimia.
Parotid calculus Parotid pain and recurrent swelling occur with eating. A stone may be palpated inferior to the zygoma.
Orbital fracture A blow to the eye is followed by eyelid ecchymosis. Diplopia on vertical gaze indicates muscle entrapment.
Mandibular fracture Following jaw trauma, there is a palpable step-off and the teeth do not seat together normally.
Maxillary fracture With facial trauma, look for unilateral epistaxis, periorbital and subconjunctival ecchymoses, a flat cheek contour, a notch in the bony orbital rim, an anesthetic upper lip, diplopia, decreased transillumination of the maxillary sinus, and subcutaneous emphysema. With a LeFort I fracture, there will be a floating upper jaw with a midpalatal ecchymotic line. A LeFort II fracture produces a “dish face” with massive facial swelling, diplopia, and malocclusion. A LeFort III fracture causes mobility of the upper face on the cranial vault, with CSF rhinorrhea.
Myocardial infarction Severe lower jaw or neck pain usually, but not always, occurs in association with chest pain.
Connective tissue disease Inflammatory arthritis of the temporomandibular joint is associated with rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, and Reiter syndrome.
Temporal arteritis Suspect this in a patient older than 50 years of age with jaw claudication, a tender, ropy, or nodular temporal artery, or transient visual loss.
Cavernous sinus thrombosis An acute onset of photophobia, headache, ophthalmoplegia, chemosis, and proptosis occurs in a patient in an extremely toxic condition.
Glossopharyngeal neuralgia Paroxysmal, severe unilateral pain involves the ear, larynx, tonsil or tongue, radiating toward the ear. Triggers include chewing, yawning, swallowing, and certain tastes.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Toothache
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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» Next page: Jaw pain (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
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