Temporal arteritis: temple pain and jaw pain when chewing

MSD Manuals defines giant cell arteritis as long-term inflammation of the large and medium-sized arteries of the head, neck and upper part of the body. The most typically affected vessel is the temporal artery, which runs through the temple; this vessel supplies part of the scalp, the jaw muscles and the optic nerves. The cause is unknown. MSD writes that the condition is more common in women and typically affects people over 50, most often around the age of 70.

The mechanism of the jaw pain resembles the cramping pain in the leg that comes on when walking. When the inflamed vessel narrows, the chewing muscles get enough blood at rest, but once they start working and their need rises, the blood is not enough and the muscle hurts. This is called jaw claudication. MSD describes it as the jaw muscles aching and tiring shortly after you start chewing; it adds that the tongue can also hurt when eating or talking. The NHS also lists jaw pain when eating or talking among the main symptoms.

The value of this symptom has been measured. In a meta-analysis combining 68 studies covering 14,037 patients assessed for suspected temporal arteritis, jaw claudication was one of the findings that most strongly pointed to the condition; thickening of the temple artery and an absent pulse in the temple were also strong findings. In blood tests, an erythrocyte sedimentation rate (ESR) not above 40 mm/hour clearly lowered the probability of the condition. Even so, the authors stress that no single finding is enough on its own to make or rule out the diagnosis.

The real danger is the eye. MSD writes that if blood flow to the optic nerve is cut off, sudden and permanent blindness can develop, and that before this there may be double or blurred vision, large blind spots or sudden loss of vision in one eye that passes within a few minutes. In a cohort of 350 patients in England diagnosed by imaging or biopsy, 28.9 percent of patients had visual symptoms, 13.7 percent had loss of vision in one or both eyes, and lost vision rarely came back. After a fast-track diagnosis and treatment pathway was set up at the same centre, the rate of vision loss fell from 18.7 percent to 11.5 percent.

Where it overlaps with dentistry is the jaw. In a case series in Germany reviewing the records of, and interviews with, 6 patients whose diagnosis was confirmed by biopsy, all the patients had symptoms in the mouth and face; for 5 of them, a dental examination was part of the path to diagnosis, and for 3 of them the dentist was the first person they went to. The time to diagnosis ranged from about 4 weeks to 5 months. A case report from Israel also writes that temporal arteritis can be mistaken for a jaw joint disorder, and that this diagnosis should be considered when jaw claudication, mouth opening limited by a hard resistance and temple pain come together in an older patient.

The confusion also runs the other way: a very common cause of temple pain is jaw joint and chewing muscle problems (TMD). In a small study of 10 patients in Scotland referred to an emergency eye clinic with suspected temporal arteritis, the TMD score was clearly higher in those who met fewer than 3 of the temporal arteritis criteria. The authors write that TMD is an important cause of temple pain when temporal arteritis is unlikely, and that referral to a dentist may be appropriate. So both directions are possible; the whole set of symptoms and the blood tests make the distinction.

The condition is not limited to the head and jaw. MSD writes that there may be fever, weakness, unintentional weight loss and sweating, and that symptoms can start slowly over weeks or suddenly; 40–60 percent of patients also have symptoms of polymyalgia rheumatica, which causes pain and stiffness in the neck, shoulders and hips that is worse in the morning and at night. Rarely, the blood flow to the brain is cut off and a stroke develops, or there is a tear or widening in the wall of the main artery (aorta).

The treatment also concerns the dentist. The NHS writes that temporal arteritis is treated with steroids (usually prednisolone), at a high dose for the first few weeks and then at a lower dose, possibly for years, and that a stomach-protecting medicine and a bisphosphonate medicine to prevent bone thinning may also be given against the side effects of steroids. MSD states that steroids can raise blood sugar and reduce bone density in older people. If you are taking these medicines, make sure you tell your dentist before a tooth extraction or an implant is planned; the decision on extraction and implants is made with this information.

The first list is signs that make it more likely the jaw pain is coming from the jaw joint or the muscles. If an item in the second list applies to you, especially if you are over 50, temporal arteritis should be considered and it should not be left to wait. The examination and blood tests make the distinction.

Time matters in temporal arteritis: treatment is started at the moment of suspicion, before the diagnosis is confirmed. That is why the sequence starts with the emergency situation.

1. 1

   Emergency if there are visual symptoms

   If there is loss of vision, blurred or double vision or a temporary blackout in one eye, do not wait; call 112 or go to A&E. The NHS asks for people with vision problems to be seen by an eye doctor in hospital the same day.

2. 2

   Symptoms and examination of the temples

   The NHS writes that the doctor asks about your symptoms and examines your temples. MSD states that the doctor checks whether the temple arteries are hard, raised or tender. It is important to describe how long after you start chewing the jaw pain comes and whether it goes away when you stop.

3. 3

   Blood tests

   MSD writes that anaemia, a very high ESR and a raised C-reactive protein level show inflammation and support the diagnosis. In the meta-analysis, an ESR not above 40 mm/hour clearly lowered the probability of the condition, but did not rule it out on its own.

4. 4

   Steroid treatment starts straight away

   The NHS writes that because of the risk of vision loss, steroids are started before the diagnosis is confirmed. MSD states that the result of a biopsy done within 2 weeks of starting treatment is not affected; in other words, there is no need to wait for the biopsy before treatment.

5. 5

   Confirmation by ultrasound or biopsy

   The NHS writes that the specialist may ask for an ultrasound scan of the temple arteries or for a small piece to be taken from the temple artery under local anaesthetic (biopsy). MSD states that ultrasound can sometimes make a biopsy unnecessary.

6. 6

   Long-term follow-up

   The NHS writes that the response to treatment and the side effects are monitored at regular check-ups. The steroid dose is reduced according to the doctor's plan as the symptoms improve.

Treating temporal arteritis is not the dentist's field, but that of rheumatology, eye and internal medicine specialists. The dentist's job is to recognise this picture and send the patient to the right place without delay. The medicine and the dose are decided by the doctor who follows you up.

What these mistakes have in common is lost time. Because loss of vision may not be reversible, each of them matters.

MSD writes that with treatment most patients recover completely, but the condition can come back. The sequence below is the usual course described by the NHS and MSD; the plan of the doctor who follows you up comes first.

1. The moment of suspicion

   Steroids are started before the diagnosis is confirmed; blood tests and ultrasound or a biopsy are planned afterwards.

2. The first few weeks

   The high-dose steroid period. The headache, scalp tenderness and jaw pain are expected to ease during this period; if they do not, tell your doctor.

3. The dose reduction period

   As the symptoms improve, the dose is lowered slowly according to the doctor's plan. The NHS writes that this period can last several years, and MSD that most patients take medicine for at least 2 years.

4. The long term

   At regular check-ups, whether the condition has come back and the side effects of steroids are monitored. If headache, jaw pain or a visual symptom comes back, tell your doctor straight away.

We do not give a single figure here, because treating temporal arteritis is not the dentist's field but that of rheumatology and ophthalmology, and its scope varies from person to person. These are the items that determine the scope:

When the diagnosis is made

An early diagnosis reduces the risk of vision loss; unnecessary dental treatment that might be done for the jaw pain is also avoided.

Diagnostic method

In addition to blood tests, ultrasound, a biopsy or MR angiography for the large vessels may be needed.

Length of treatment and additional medicines

Steroids usually go on for years; immunosuppressants and stomach- and bone-protecting medicines widen the scope.

Involvement of the eyes or vessels

If there is a vision problem or involvement of the large vessels, specialist follow-up is more intensive.