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Assessing pain – is it cause or effect?

Case

history

Fiona is feeling very stressed about a pain at the angle of her jaw; it developed a few days ago and is also giving

her earache. The pain is interfering with

eating, work and her social life.

Dr Melanie Wynne-Jones discusses.

Some symptoms, including pain, can be a sign of the patient's 'dis-ease' rather than disease per se so it is important to consider whether Fiona's pain is causing her stress or whether things may actually be the other way round. Individuals' pain thresholds vary, but pain is not an absolute and how bad it feels depends on many things. For example, pain can feel much worse if we are tired, hungry, anxious or depressed, or frightened that the pain is a sign of some terrible disease such as heart disease or cancer (concerned family or friends may fuel this fear).

Patients may also be worried their symptoms will interfere with important commitments such as work, caring for a family member, a wedding or a holiday.

People who use forceful language to describe their pain make assessment even more difficult. If a pain is 'agony', 'stressing me out' or 'doing my head in' this may reflect the patient's coping mechanisms or current life events rather than the true severity of the pain.

What are the causes of jaw pain?

This area is anatomically crowded and the following list is not ranked or exhaustive:

lTemporomandibular joint (TMJ) dysfunction

lDental problems

lEar problems such as otitis media or externa, eustachian tube dysfunction or, rarely, tumours

lTonsillitis – pain may be referred to the ear, peritonsillar abscess (quinsy) causes trismus

lSinusitis

lParotid gland disorders – infections (classically mumps), abscess, stone or tumour

lLymphadenopathy – infective, metastatic

lTrigeminal neuralgia – shooting or lancinating pain in the distribution of the trigeminal nerve, often triggered by touch, chewing, talking or cleaning teeth

lTemporal arteritis – jaw claudication may be a prominent symptom, plus temporal artery tenderness, visual disturbance and/or symptoms of polymyalgia rheumatica

lHerpes zoster – pain may precede the rash by several days or persist for months as in post-herpetic neuralgia

lCellulitis

lTension, migraine or cluster headaches

lReferred pain from cervical spine

lMaxillary/mandibular bone disorders – infection, trauma, tumours

lOther head and neck tumours

lAngina and oesophageal pain occasionally radiate to the jaw.

A thorough examination of the face, mouth, ears and neck may reveal the cause although a full blood count, erythrocyte sedimentation ratio, X-rays or hospital or dental referral may be needed.

Temporomandibular joint dysfunction

This may be due to myofascial pain or internal derangement of the TMJ itself (less common), and/or related to dental problems such as malocclusion or joint hypermobility syndromes.

The commonest symptoms are a dull ache in and around the ear, face or neck, headache, joint noise such as clicking, grating or popping and limited mouth opening and spasm. Symptoms are usually made worse by chewing, including nail-biting and/or stress.

Myofascial pain is caused by spasm in the masticatory muscles (internal and external pterygoids, temporalis and masseter) and

may be part of a wider disorder, fibromyalgia.

It is commoner in women and often related

to nocturnal bruxism (teeth grinding) and stress. Palpation of the joint in action may reveal tenderness, crepitus or instability; the masticatory muscles may also be tender.

Pain often resolves over a few months

but may be helped by:

lResting the joint – a soft diet requiring

little chewing; avoid biting apples or yawning widely

lTrying to reduce nail-biting and teeth-clenching or grinding

lPainkillers – oral or external topical NSAIDs

lLocal heat

lDental treatment

lWearing a night splint (this must be fitted by a dentist)

lPhysiotherapy and joint exercises

lRelaxation techniques

lAcupuncture

lTreatment of underlying stress

lReferral to a maxillofacial surgeon.

Should you treat suspected dental causes?

No, unless you have dental training, although you must recommend getting a dental

opinion.

A dental abscess may well need antibiotics, but you are not qualified to say whether

further treatment is required either now or

later.

If you prescribe, the patient's symptoms

may partially resolve, persuading them that dental advice is not needed and risking

the loss of potentially salvageable teeth or undiagnosed bone or cerebral abscess or malignancy.

A further issue is that GPs are not paid to do dental work, except arresting dental haemorrhage, but are often easier and cheaper to access than dentists.

NHS dentists must arrange emergency care, including out-of-hours, and the primary care organisation has responsibility for providing NHS dentistry.

So if you are faced with a patient who claims to be unable to get an appointment with an NHS dentist, you could suggest they ring their dentist again, or give them the telephone number of the officer responsible for general dental services.

Key points

lThe perception of pain may be worsened by or contribute to patients' stress and distress

lSymptoms at the angle of the jaw may be caused by one of many disorders

lTemporomandibular joint pain usually responds to simple measures

lGPs are not trained, paid or insured to diagnose and manage dental problems – these should be referred promptly to a dentist

Self-help resources for patients with TMJ pain

British Association of Oral and Maxillofacial Surgeons.

Royal College of Surgeons of England

35-43 Lincoln's Inn Fields

London WC2A 3PN

Tel: 020 7405 8074

Fax: 020 7430 9997 www.baoms.org.uk

Melanie Wynne-Jones is a GP in Marple, Cheshire

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