Jaw pain
Jaw pain may arise from either of the two bones that hold the teeth in the jaw — the maxilla (upper jaw) and the mandible (lower jaw). Jaw pain also includes pain in the temporomandibular joint (TMJ), where the mandible meets the temporal bone. (See Associated disorder: Temporomandibular joint disorders.)
Jaw pain may develop gradually or abruptly and may range from barely noticeable to excruciating, depending on its cause. It usually results from disorders of the teeth, soft tissue, or glands of the mouth or throat or from local trauma or infection. Systemic causes include musculoskeletal, neurologic, cardiovascular, endocrine, immunologic, metabolic, and infectious disorders. Life-threatening disorders, such as myocardial infarction (MI) and tetany, also produce jaw pain, as do certain drugs (especially phenothiazines) and dental or surgical procedures.
Jaw pain is seldom a primary indicator of any one disorder; however, some causes are medical emergencies.
Emergency Actions
Sudden severe jaw pain, especially when associated with chest pain, shortness of breath, or arm pain, requires prompt evaluation because it may herald a life-threatening disorder. Perform an electrocardiogram and obtain blood samples for cardiac enzyme levels. Administer oxygen, morphine sulfate, and a vasodilator as indicated.
History
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.
Physical assessment
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" (2.9 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.
Medical causes
Angina pectoris
Angina may produce jaw pain (usually radiating from the substernal area) and left arm pain. Angina is less severe than the pain of an MI. It’s commonly triggered by exertion, emotional stress, or ingestion of a heavy meal and usually subsides with rest and the administration of nitroglycerin. Other signs and symptoms include shortness of breath, nausea and vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations.
Arthritis
With osteoarthritis, aching jaw pain increases with activity (talking, eating) and subsides with rest. Other features are crepitus heard and felt over the TMJ, enlarged joints with a restricted range of motion, and stiffness on awakening that improves with a few minutes of activity. Redness and warmth are usually absent.
Rheumatoid arthritis causes symmetrical pain in all joints, including the jaw. The joints display limited range of motion and are tender, warm, swollen, and stiff after inactivity, especially in the morning. Myalgia is common. Systemic signs and symptoms include fatigue, weight loss, malaise, anorexia, lymphadenopathy, and mild fever. Painless, movable rheumatoid nodules may appear on the elbows, knees, and knuckles. Progressive disease causes deformities, crepitation with joint rotation, muscle weakness and atrophy around the involved joint, and multiple systemic complications.
Head and neck cancer
Many types of head and neck cancer, especially those of the oral cavity and nasopharynx, produce aching jaw pain of insidious onset. Other findings include a history of leukoplakia ulcers of the mucous membranes; palpable masses in the jaw, mouth, and neck; dysphagia; bloody discharge; drooling; lymphadenopathy; and trismus.
Hypocalcemic tetany
Besides painful muscle contractions of the jaw and mouth, this life-threatening disorder produces paresthesia and carpopedal spasms. The patient may complain of weakness, fatigue, and palpitations. Examination reveals hyperreflexia and positive Chvostek’s and Trousseau’s signs. Muscle twitching, choreiform movements, and muscle cramps may also occur. With severe hypocalcemia, laryngeal spasm may occur with stridor, cyanosis, seizures, and cardiac arrhythmias.
Ludwig’s angina
Ludwig’s angina is an acute streptococcal infection of the sublingual and submandibular spaces that produces severe jaw pain in the mandibular area with tongue elevation, sublingual edema, and drooling. Fever is a common sign. Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.
Myocardial infarction
Initially, this life-threatening disorder causes intense, crushing substernal pain that’s unrelieved by rest or nitroglycerin. The pain may radiate to the lower jaw, left arm, neck, back, or shoulder blades. (Rarely, jaw pain occurs without chest pain.) Other findings in MI include pallor, clammy skin, dyspnea, excessive diaphoresis, nausea and vomiting, anxiety, restlessness, a feeling of impending doom, low-grade fever, decreased or increased blood pressure, arrhythmias, an atrial gallop, new murmurs (in many cases from mitral insufficiency), and crackles.
Osteomyelitis
Bone infection after trauma, sinus infection, dental injury, or surgery (dental or facial) may produce diffuse, aching jaw pain along with warmth, swelling, tenderness, erythema, and restricted jaw movement. Acute osteomyelitis may also cause tachycardia, sudden fever, nausea, and malaise. Chronic osteomyelitis may recur after minor trauma.
Sinusitis
Maxillary sinusitis produces intense boring pain in the maxilla and cheek that may radiate to the eye. This type of sinusitis also causes a feeling of fullness, increased pain on percussion of the first and second molars and, in those with nasal obstruction, the loss of the sense of smell. Sphenoid sinusitis causes scanty nasal discharge and chronic pain at the mandibular ramus and vertex of the head and in the temporal area. Other signs and symptoms of both types of sinusitis include fever, halitosis, headache, malaise, cough, sore throat, and fever.
Suppurative parotitis
With suppurative parotitis, bacterial infection of the parotid gland by Staphylococcus aureus produces abrupt onset of jaw pain, high fever, and chills. Other findings include erythema and edema of the overlying skin; a tender, swollen gland; and pus at the second top molar (Stensen’s ducts). Infection may lead to disorientation; shock and death are common.
Temporal arteritis
Temporal arteritis produces sharp jaw pain after chewing or talking. Nonspecific signs and symptoms include low-grade fever, generalized muscle pain, malaise, fatigue, anorexia, and weight loss. Vascular lesions produce jaw pain; throbbing, unilateral headache in the frontotemporal region; swollen, nodular, tender and, possibly, pulseless temporal arteries; and, at times, erythema of the overlying skin.
Temporomandibular joint disorders
TMJ disorders produce jaw pain at the TMJ; spasm and pain of the masticating muscle; clicking, popping, or crepitus of the TMJ; and restricted jaw movement. Unilateral, localized pain may radiate to other head and neck areas. The patient typically reports teeth clenching, bruxism, and emotional stress. He may also experience ear pain, headache, deviation of the jaw to the affected side upon opening the mouth, and jaw subluxation or dislocation, especially after yawning.
Trauma
Injury to the face, head, or neck — particularly fracture of the maxilla or mandi-
ble — may produce jaw pain and swelling and decreased jaw mobility. Associated findings include hypotension and tachycardia (indicating shock), lacerations, ecchymoses, and hematomas. Rhinorrhea or otorrhea indicates the leakage of cerebrospinal fluid; blurred vision indicates orbital involvement.
Trigeminal neuralgia
Trigeminal neuralgia is marked by paroxysmal attacks of intense unilateral jaw pain (stopping at the facial midline) or rapid-fire shooting sensations in one division of the trigeminal nerve (usually the mandibular or maxillary division). This superficial pain, felt mainly over the lips and chin and in the teeth, lasts from 1 to 15 minutes. Mouth and nose areas may be hypersensitive. Involvement of the ophthalmic branch of the trigeminal nerve causes a diminished or absent corneal reflex on the same side. Attacks can be triggered by mild stimulation of the nerve (for example, lightly touching the cheeks), exposure to heat or cold, or consumption of hot or cold foods or beverages.
Other causes
Drugs
Some drugs, such as phenothiazines, affect the extrapyramidal tract, causing dyskinesias; others cause tetany of the jaw secondary to hypocalcemia.
Special considerations
If the patient is in severe pain, withhold food, liquids, and oral medications until the diagnosis is confirmed. Administer an analgesic.Prepare the patient for diagnostic tests such as jaw X-rays. Apply an ice pack if the jaw is swollen, and discourage the patient from talking or moving his jaw.
Pediatric pointers
Be alert for nonverbal signs of jaw pain, such as rubbing the affected area or wincing while talking or swallowing. In infants, initial signs of tetany from hypocalcemia include episodes of apnea and generalized jitteriness progressing to facial grimaces and generalized rigidity. Finally, seizures may occur.
Jaw pain in children sometimes stems from disorders uncommon in adults. Mumps, for example, causes unilateral or bilateral swelling from the lower mandible to the zygomatic arch. Parotiditis due to cystic fibrosis also causes jaw pain. When trauma causes jaw pain in children, always consider the possibility of abuse.
Patient counseling
Teach the patient about his disorder and its treatments. Demonstrate how to insert mouth splints and discuss ways to reduce stress. Help the patient identify and avoid factors that may trigger an attack.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Toothache
Read excerpts from these other book chapters related to Toothache:
Medical Books Excerpts
- JAW PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- TOOTHACHE
- "Differential Diagnosis in Primary Care" (2007)
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- Jaw pain
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Jaw pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Jaw pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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- Jaw pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Jaw pain
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
- TOOTHACHE
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Toothache
» Next page: Jaw pain (Nursing: Interpreting Signs and Symptoms)
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