Reasoning GP · Algorithm · 1-page summary
Jaw pain in adults
For: adults with acute or chronic jaw pain in general practice. Not for: children; pregnancy, significant immunosuppression, active cancer treatment and major comorbidity need adapted management. Local emergency, dental and OMFS pathways apply.
Core rule: exclude ACS, giant cell arteritis (GCA) and airway-threatening infection before TMD or dental causes. Jaw claudication at 50+ is GCA until proven otherwise: start prednisolone without waiting for tests.
0Stop — call 999 now
- Suspected ACS: jaw, neck, arm or epigastric pain that is exertional or pressure-like, with chest discomfort, breathlessness, sweating, nausea or syncope → 999. Do not delay for troponin.
- Airway or sepsis: stridor, drooling or unable to swallow saliva, rapidly progressive floor-of-mouth or neck swelling (Ludwig's, deep-space infection), severe sepsis → 999
- Suspected GCA with visual symptoms (visual loss, amaurosis fugax, diplopia) → treat immediately per the local GCA pathway + 999 / same-day emergency ophthalmology per the local emergency pathway.
- Trismus with dysphagia, spasms, respiratory difficulty or autonomic instability (severe tetanus) → 999
1Triage by pattern — after block 0
| Pattern | Route |
|---|---|
| Age ≥50 | Jaw or tongue claudication, new headache, scalp tenderness, PMR or constitutional symptoms → prednisolone now + Same-day GCA pathway, whatever the markers |
| Locked jaw | Cannot open at all after dental work or trauma → Same-day dental / OMFS |
| Tooth-related | Percussion or cold pain, swollen gum → dentist or NHS 111 urgent dental services |
| Pre-auricular ache | Click, deviation, limited opening, worse chewing → likely TMD (block 4) |
2Screen — one row is enough
- Trismus or dental infection with fever, swelling, dysphagia, spreading cellulitis or systemic illness; deep-space infection without airway compromise → Same-day emergency
- Trismus + dirty or unvaccinated wound (tetanus) → Same-day emergency hospital
- Oral ulcer >3 weeks or persistent unexplained neck lump → consider suspected cancer pathway (NG12). Lip or oral lump, red or red-and-white patch → consider dentist ≤2 weeks
- Hard, fixed jaw or salivary mass; exposed bone or non-healing socket after radiotherapy or MRONJ-risk medicines → Urgent OMFS / ENT; rapidly enlarging or airway affected → Same-day
- Facial pain + persistent numbness or neurological signs → Urgent neuroimaging / neurology (NG127)
3Assess
☐ Observations, temperature; airway (voice, drooling, saliva) ☐ Temporal arteries, scalp ☐ TMJ, jaw muscles, mouth opening measured ☐ Whole oral cavity, parotid, nodes ☐ Trigeminal sensation, cranial nerves
GCA: same-day FBC, ESR, CRP. ECG if ACS not excluded, never delaying 999. Not in primary care: troponin, CT, TMD imaging.
4Classify — only if the screen is negative
- TMD (commonest) — pre-auricular ache, click, limited opening; clinical diagnosis → self-management.
- Dental — pulpitis, abscess, pericoronitis → dentist / NHS 111 urgent dental services.
- Trigeminal neuralgia — unilateral electric shocks lasting seconds to 2 minutes, trigger zones → carbamazepine; MRI desirable, not a prerequisite.
- Salivary — swelling with meals (stone); pus from the duct + fever (sialadenitis); bilateral → consider mumps (notify UKHSA).
- Referred — neck, sinus, ear, quinsy. Persistent idiopathic facial pain → specialist.
- Uncertain — record the working diagnosis and exclusions; refer (block 6) rather than relabel.
5Treat today — doses: NICE/SPC, BNF, local formulary
- GCA: prednisolone 40–60 mg once daily per the local pathway, today; visual loss → emergency hospital.
- TMD: explain; soft diet short-term; avoid gum, wide opening, clenching; heat or cold; jaw exercises; short-term ibuprofen if safe, or paracetamol.
- Typical TN: offer carbamazepine, low dose, titrate; baseline FBC, LFTs, U&Es, sodium; HLA-B*15:02 if Han Chinese or Thai; check contraception.
- Dental abscess: no antibiotics unless spreading or systemic infection or immunosuppression — then urgent dental / OMFS advice + local guideline.
6Refer routinely
- TMD: review at 4–6 weeks; beyond ~3 months, worsening, marked restriction or uncertainty → OMFS / TMD clinic.
- TN uncertain, atypical, or carbamazepine ineffective, not tolerated or contraindicated → specialist advice / neurology (urgent with red flags).
- Bruxism, splint, periodontal disease → dentist. MRONJ-risk medicines: dental check before extractions; never stop them independently.
7Never reassure by
- Normal ESR or CRP, or a pending ultrasound or biopsy, in suspected GCA.
- No visual symptoms: jaw claudication alone triggers the GCA pathway.
- Waiting for an ECG or troponin when ACS is suspected.
- Antibiotics for a dental abscess: without drainage they will fail.
- Watching an oral ulcer or patch beyond 3 weeks.
- A response to carbamazepine: it does not confirm trigeminal neuralgia.
8Safety-net — say it, then document it
999 “Call 999 for jaw pain with chest pain or sweating; difficulty breathing, noisy breathing, drooling, being unable to swallow saliva, a voice change or fast-spreading swelling under the jaw or in the neck; or any new problem with your vision.”
Same day: “Contact us today if jaw stiffness worsens with fever or swelling, swelling spreads to your neck, high fever, or (if 50+) new headache, scalp tenderness or jaw pain on chewing.” Antibiotics not working → review at 24–48 h. Carbamazepine + rash, ulcers, sore throat, fever or bruising → stop, same-day review.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies; GCA considered if 50+
Observations, airway and mouth opening recorded
Whole oral cavity and neck examined
Diagnosis, exclusions, route or review date set
Safety-net given; drug rationale recorded
Summary of the full Reasoning GP jaw pain algorithm, which holds the history, examination, investigations and evidence. Sources: BSR GCA 2020; NICE NG12 (updated April 2026), NG127, CG173; local GCA pathway; MHRA; UKHSA. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.