What Do I Do Next: Jaw Pain

Sean Nordt MD, Mike Weinstock MD, and Mizuho Spangler MD

Case

A 21-year-old man presents to the Urgent Care (UC) reporting right-sided temporomandibular joint (TMJ) pain and a “loose” feeling with catching, pain, and popping in the right TMJ. He can chew and eat, has no history of trauma, and also reports an increase in the severity of his psoriasis.

Physical Exam: No dislocation; normal range-of-motion of the jaw. No oral exam documented.

Summary: A young man with unilateral jaw pain, but his story and exam do not completely add up.

We need to know more. Is there any swelling, erythema, or other evidence of cellulitis or abscess? Any past medical history of TMJ problems? Any ecchymosis or sign of trauma? An oral exam needs to be documented to rule out a dental abscess as a source of the pain.

When we examine a joint, we always look at the joint above and the joint below. Similarly, when examining the jaw, remember to evaluate surrounding structures like the teeth, oropharynx, ear, and scalp. In an older person, it is also important to consider temporal arteritis and acute coronary syndrome. Consider if the patient has recently had dental work or facial surgery, or chew tobacco or gum.

Another important question in a young man is to ask is about drug use, particularly if the oral exam reveals: gingivitis; multiple dental caries; demineralized, worn, or cracked teeth; or petechiae along gingival ridges.

in The drug most likely to cause bruxism is MDMA (e.g. ecstasy, Molly). This bruxism is serotonergically -mediated. This is the reason that one piece of paraphernalia at raves is often a baby pacifier, which helps people suck instead of grind their teeth. MDMA is also a sympathomimetic, which causes xerostomia, further increasing the likelihood of oral bacterial overgrowth and dental caries.

serotonergically Other pharmacologic causes of bruxism include phenothiazines (the original antipsychotic drugs that are not used very much use anymore), and also SSRIs or tricyclic antidepressants, because they are also serotonergic.

antidepressants, Poor dentition and its consequences is frequently seen in “ meth mouth ” from use of methamphetamines. Repetitive chewing behaviors are common with any sympathomimetic drug, like cocaine and bath salts, and occur in part from stimulation and in part from xerostomia. Keep in mind that there is a lot of contamination amongst drugs, so patients may report that they have taken bath salts recently, but they could very easily have consumed ecstasy that was mixed in.

It is important to identify people on sympathomimetic drugs. Because other than trauma, there are 2 things that will kill them:

1. Hyperthermia

2. Hyponatremia (these drugs can induce and SIADH-like state, and the hyperthermia causes thirst, so they consume a lot of free water and sweat out a lot of salt).

Case conclusion:

The next day, the patient was using heroin, cocaine, and bath salts, and he was dropped off at the Emergency Department apneic, cyanotic, slumped over, and drooling. He received oxygen immediately and the staff started bagging him, initiated an IV, and administered naloxone (Narcan). He regained consciousness and was monitored for several hours before being discharged.

Take-home Point: If things are not adding up, or if there is some discordance between the diagnosis being considered and the physical exam, dig a little deeper and expand your thought process to include age-specific considerations, such as drug use.