Assessing pain – is it cause or effect?
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
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
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
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
lWearing a night splint (this must be fitted by a dentist)
lPhysiotherapy and joint exercises
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
A dental abscess may well need antibiotics, but you are not qualified to say whether
further treatment is required either now or
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.
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