Jaw Pain and Swellings
Pain and/or swelling of the jaw results most commonly from dental conditions. In the upper jaw, pain may also result from infection of the paranasal sinuses. The latter condition is considered under Facial swellings (p. 134).
Causes
Traumatic
Temporomandibular Joint
History
Traumatic
History of trauma, e.g. fights, road traffic accidents. Fracture of the mandible is the most common.
Infective
Dental abscess presents with a dull ache in the jaw, becoming throbbing and severe. There is often accompanying malaise and loss of appetite. Previous history of dental caries. Acute osteomyelitis of the mandible is rare. It may follow dental infection or tooth extraction. There may be a history of fractures, irradiation, leukaemia, diabetes, malnutrition, alcoholism or immunosuppression. There is a severe, throbbing deep-seated pain. The patient has difficulty opening the mouth and swallowing due to muscle oedema. Actinomycosis presents with swelling of the jaw with persistent low-grade infection.
Temporomandibular joint
Temporomandibular joint pain dysfunction syndrome results from grinding and clenching the teeth. The patient may have had a stress-related illness. Pain arises in the region of the temporomandibular joint or ear, which may be associated with a clicking noise and is aggravated by wide opening of the mouth, as with yawning and chewing. Rheumatoid arthritis of the temporomandibular joint is rare. Other signs and symptoms of rheumatoid arthritis are usually apparent. Osteoarthritis usually causes pain, swelling and limitation of jaw movement. Temporomandibular joint dislocation may be recurrent, habitual or isolated. The condyle is displaced forwards and upwards into the temporal fossa. The patient’s mouth remains open and cannot be closed following yawning, tooth extraction or general anaesthesia. The condition may be unilateral or bilateral. The patient presents with an open mouth, which he or she cannot close, and pain due to muscle spasm.
Cystic
Cysts often present as asymptomatic lucencies on radiographs. Otherwise, they present as painless swellings, which may reach a large size. If the cyst becomes infected, the patient presents with pain, swelling and discharge. Occasionally pathological fractures occur. A dental cyst is attached to the root of a normally erupted but decayed tooth; the swelling grows slowly. Dentigerous cysts contain an unerupted tooth.
Neoplastic
The patient presents with a jaw swelling which grows steadily and often painlessly. Giant cell granuloma may erode through bone to produce a soft-tissue purplish swelling on the gum. Ameloblastomas usually occur around the age of 30–50 years and are symptomless until the swelling becomes obtrusive. Osteogenic sarcoma of the jaw is extremely rare. Initially it is painless but becomes painful as it grows. Teeth may be loosened. The patient may complain of paraesthesia due to involvement of the mental nerve. Coughing may be a symptom if lung metastases have occurred. Burkitt’s tumour is associated with EBV. It is a malignant tumour of B lymphocytes. It is endemic in certain parts of Africa and New Guinea. Most commonly it affects children below the age of 12 years. The child presents with a progressive painless swelling of the jaw. Secondary deposits in the jaw are uncommon but may arise from lung, breast, thyroid, prostate or kidney.
Others
With post-herpetic neuralgia, there is usually a history of herpes zoster in the distribution of the trigeminal nerve. The pain tends to be distributed in a division of the trigeminal nerve. Pain may involve a large area of the face, rather than just the region of the jaw. Referred pain to the jaw is common with angina. The patient usually complains of associated chest pain and radiation of the pain down the left arm. With giant cell arteritis, there will be pain in the jaw on chewing (jaw claudication). In addition, there will be other symptoms of temporal arteritis, e.g. headache precipitated by touch and tenderness in the temporal area. With osteonecrosis of the jaw, ask about steroid and bisphosphonate therapy for osteoporosis and past history of radiotherapy.
Examination
Traumatic
Check for a normal bite. Bruising, swelling, crepitus, tenderness. Bloodstained saliva. Broken teeth. Step deformities in occlusion.
Infective
With dental abscesses, there is reddening of the mucosa with a firm, hot, acutely tender, boggy swelling. The dental abscess may point on the outer side of the jaw. There may be associated dental caries and gingivitis. Cervical lymphadenopathy is usually present. With acute osteomyelitis, there is usually difficulty in opening the mouth and swallowing due to muscle oedema. There is a tender, red, painful swelling overlying the mandible. In actinomycosis, there may be multiple discharging sinuses, usually near the angle of the jaw, on which characteristic ‘sulphur granules’ may be seen discharging.
Temporomandibular joint
Diagnosis of temporomandibular joint dysfunction syndrome is usually made from the history. There is usually trismus and spasm around the joint. In rheumatoid arthritis, there may be tenderness and swelling over the joint. In osteoarthritis, there may be swelling over the joint and limitation of movement. In temporomandibular joint dislocation, the condyles are palpable anterior to the articular eminence. The mouth is gagged open.
Cystic
Often the only abnormality on examination is a swelling in the bones. Sometimes the bone is so thin that it crackles when touched, like a broken eggshell. With dentigerous cysts, the tooth remains unerupted and therefore a tooth will be missing when the teeth are counted.
Neoplastic
Often the only abnormality is a bony swelling, which grows steadily, initially without pain. With giant cell granuloma it may rarely erode through the bone to produce soft-tissue purplish swelling on the gum. Osteogenic sarcoma is initially painless but as it grows, it may loosen the teeth. Check for loose teeth and paraesthesia in the distribution of the mental nerve. Examine the lung for metastases. With Burkitt’s lymphoma, there is progressive painless swelling. The eye may be displaced and the mouth partly occluded by the swelling. Secondary deposits often present as painful lesions within the bone. Check for a previous history of malignancy and check the lungs, breast, prostate, kidney and thyroid for the site of a primary.
Other
The diagnosis of post-herpetic neuralgia is usually made on the history, as is referred pain from myocardial ischaemia.
General Investigations
■ FBC, ESR
Hb ↓ malignancy. WCC ↑ infection, leukaemia, acute osteomyelitis.
■ LFTs
Alcoholism (acute osteomyelitis commoner).
■ Blood glucose
Diabetes (acute osteomyelitis).
■ Swab
C&S. Dental infection. Actinomycosis.
■ Temporomandibular joint X-rays
Dislocation. Osteoarthritis. Rheumatoid arthritis.
