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.
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 a myocardial infarction (MI) and tetany, also produce jaw pain as well as 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.
Ask the patient when the jaw pain began. Did it arise suddenly or gradually? Is it more severe or frequent now than when it first occurred? 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 myocardial infarction. Perform an electrocardiogram and obtain blood samples for cardiac enzyme levels. Administer oxygen, morphine sulfate, and a vasodilator as indicated.
History and physical examination
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.
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, which usually affects the small joints of the hand, 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 (ROM), and stiffness on awakening that improves with a few minutes of activity. Redness and warmth are usually absent.
Rheumatoid arthritiscauses symmetrical pain in all joints (commonly affecting proximal finger joints first), including the jaw. The joints display limited ROM 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 a 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.
Gender cue
Rheumatoid arthritis usually appears in early middle age, between ages 36 and 50, and most commonly in women.
Head and neck cancer
Many types of head and neck cancer, especially 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, hypocalcemic tetany — a 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
A fever is a common sign
Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.
MI
Initially, MI 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 include pallor, clammy skin, dyspnea, excessive diaphoresis, nausea and vomiting, anxiety, restlessness, a feeling of impending doom, a low-grade fever, decreased or increased blood pressure, arrhythmias, an atrial gallop, new murmurs (in many cases from mitral insufficiency), and crackles.
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 a fever, halitosis, a headache, malaise, a cough, and a sore throat.
Suppurative parotitis
Bacterial infection of the parotid gland by Staphylococcus aureus tends to develop in debilitated patients with dry mouth or poor oral hygiene
Besides the abrupt onset of jaw pain, a high fever, and chills, 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
Most common in women older than age 60, temporal arteritis produces sharp jaw pain after chewing or talking
Nonspecific signs and symptoms include a low-grade fever, generalized muscle pain, malaise, fatigue, anorexia, and weight loss
Vascular lesions produce jaw pain; a throbbing, unilateral headache in the frontotemporal region; swollen, nodular, tender and, possibly, pulseless temporal arteries; and, at times, erythema of the overlying skin.
TMJ syndrome
TMJ syndrome is a common syndrome that produces 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, a headache, deviation of the jaw to the affected side upon opening the mouth, and jaw subluxation or dislocation, especially after yawning.
Tetanus
A rare life-threatening disorder caused by a bacterial toxin, tetanus produces stiffness and pain in the jaw and difficulty opening the mouth
Early nonspecific signs and symptoms (commonly unnoticed or mistaken for influenza) include a headache, irritability, restlessness, a low-grade fever, and chills. Examination reveals tachycardia, profuse diaphoresis, and hyperreflexia. Progressive disease leads to painful, involuntary muscle spasms that spread to the abdomen, back, or face. The slightest stimulus may produce reflex spasms of any muscle group. Ultimately, laryngospasm, respiratory distress, and seizures may occur.
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.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Toothache
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- "Nursing: Interpreting Signs and Symptoms" (2007)
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Toothache
» Next page: Jaw pain (Professional Guide to Signs & Symptoms (Fifth Edition))
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