What Causes Jaw Pain?

Patient Presentation
A 15-year-old female came to clinic with a 4 day history of increasing jaw pain and trismus. She described it as a dull pain around the temporomandibular joint (TMJ) that would awaken her from sleep occasionally and was more painful in the morning when awakening. The pain improved with ibuprofen use. She denied mouth lesions, tooth pain, tooth sensitivity, ear pain, difficulty swallowing, fever, or upper respiratory problems. She denied trauma and any clicking in the jaw. The past medical history was non-contributory.

The pertinent physical exam showed a healthy female with normal vital signs and growth parameters. HEENT showed some decreased range of motion in the TMJ. She had no obvious oral lesions or masses. She denied pain when tapping on individual teeth nor had obvious caries. Palpation of the major salivary glands was negative. She had shoddy adenopathy at the base of the mandible and her ears were normal. The diagnosis of new onset TMJ pain secondary to an unknown cause was made. The patient was referred to her own dentist who made a panoramic radiograph which found no abnormalities, but did find some increased dental wear. An interocclusal splint was fabricated, which the patient was to wear nightly. It was also recommended that patient take naproxen at regular intervals to decrease joint inflammation and pain. At followup 1 month later, she stated that her acute pain resolved within about 1 week.

Discussion
Although temporomandibular joint dysfunction is not a common complaint in children and adolescents it does occur and is an important part of the larger differential diagnosis of jaw, face, head, ear and neck pain. Medical physicians can easily forget that this is a joint like all other joints in the body and is subject to general joint problems including overuse and arthritis. Trauma after an accident is easy to identify but other problems in specific populations needs to be considered such as hemarthrosis in a patient with a bleeding disorder. Any patient who is being evaluated for possible juvenile arthritis or similar rheumatologic problems should also have the TMJ evaluated.

While TMJ problems are often managed by dental professionals and otolaryngologists the physical examination of the dental structures is important for all health care providers to remember. The physical examination should include evaluation of the TMJ by placing fingertips anterior to the tragus and palpating the joint as the patient opens and closes. Swelling, tenderness, decreased range of motion, clicking, popping and deviations should be noticed. Sounds from the joint may also be heard. The gums and soft tissues should be noted for swelling, bleeding, retraction, and discoloration. The teeth should be noted if they are missing, loose, discolored, or carious. Tapping on individual teeth and/or areas of the gums and other soft structures may help to pinpoint the affected area. Palpation of the major salivary glands and notation of any fluid that can be milked from Stetson’s duct should be noted.

Learning Point
Jaw pain like TMJ pain has a large differential diagnosis. The differential diagnosis of jaw pain includes:

• Muscular (most common cause of TMJ pain)
  • Parafunctional habits
    • Daytime including gum chewing, resting telephones between shoulder and
      ear

    • Nighttime including bruxism, clenching
• Odontogenic
  • Abscess
  • Caries
  • Orthodontic appliances
  • Temporomandibular (TMJ) joint abnormalities including TMJ syndrome, inflammatory or infectious arthritis
  • Salivary dysfunction/stone
• Infectious
  • Clostridium botulinum
  • Mumps
  • Osteomyelitis
  • West Nile virus
• Neurological
  • Otalgia
  • Trigeminal nerve abnormalities
• Tumor
  • Bone – carcinoma, fibrous dysplasia, Langerhans cell histiocytosis, osteoblastoma, osteoid osteoma, sarcoma, , metastatic disease,
  • Other – arteriovenous malformation, lymphoma, rhabdomyosarcoma
• Other
  • Drug reaction – sumitriptan, zolmitriptan, epopostenol, nicotine, vinoelbine
  • Lymphadenopathy
  • Trauma

A table with a differential diagnosis of jaw lesions by their radiographic appearance can be found in To Learn More below.

Questions for Further Discussion
1. What are indications for referral for jaw pain to a dentist?
2. What is the role of a primary care provider in dental health?

Related Cases

Disease: Temporomandibular Joint Dysfunction | Jaw Injuries and Disorders

Symptom/Presentation: Pain

Specialty: Dentistry / Orthodontia

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Temporomandibular Joint Dysfunction and Jaw Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Gupta M, Kaste SC, Hopkins KP. Radiologic appearance of primary jaw lesions in children. Pediatr Radiol. 2002 Mar;32(3):153-68.

West Nile Virus Activity – United States, July 31 – August 7, 2002, and Louisiana, January 1 -August 7, 2002. MMWR. 51:31;August 9, 2002 .

Sommer OJ, Aigner F, Rudisch A, et. al.. Cross-sectional and functional imaging of the temporomandibular joint: radiology, pathology, and basic biomechanics of the jaw. Radiographics. 2003 Nov-Dec;23(6):e14. Epub 2003 Aug 14.

Toscano P, Defabianis P. Clinical evaluation of temporomandibular disorders in children and adolescents: a review of the literature. Eur J Paediatr Dent. 2009 Dec;10(4):188-92.

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