Red flags and serious pathology

Warning

First consider MSK physiotherapy red flags and serious pathology guidance.

Specific concerns for orofacial area:

  • Age <19 or >51: new or unfamiliar symptoms/dysfunction (Cancer, growth disturbance)
  • Progressive pain/dysfunction despite treatment; non-mechanical, constant (Cancer)
  • Paroxysmal unilateral lancinating pain; autonomic signs (eye watering/redness or drooping eyelids) (Trigeminal neuralgia)
  • Unilateral headache/scalp tenderness; age>50; jaw claudication; visual symptoms; general malaise; polymyalgia (temporal arteritis)
  • Pain precipitated by exertion, coughing, sneezing; or abrupt in onset; severe; or interrupts sleep (intracranial pathology, cardiac ischaemia)
  • Severe night pain (cancer, infection, inflammation)
  • Occlusal changes; new (cancer, bone growth around TMJ), inflammatory arthritis; trauma)
  • Trismus: mouth opening less than 15 mm; Progressively worsening; no history of clicking; pain of myofascial origin (e.g. neuralgia); swollen lymph glands; suspicious intra-oral soft tissue lesion; painless limitation in young (cancer; growth disturbance)
  • Pulsating tinnitus; unilateral (vascular pathology)
  • Persistent loss of smell; purulent discharge; nasal blockage; recurrent bleeds (nasopharyngeal tumour; chronic sinusitis)
  • Hoarseness; sudden onset (cancer)
  • Globus sensation; with pain (cancer)
  • Neurological signs and symptom changes in: facial sensation/power, vision, smell, taste, swallow; or muscle atrophy, dizziness, cognitive changes, gait disturbance, reduced hand dexterity, long tract signs (intracranial pathology e.g. cancer, MS); or ipsilateral hearing loss (acoustic neuroma; nasopharyngeal tumour)
  • Trauma to head/neck; osteoporosis (fracture)
  • Weight loss (cancer)
  • Fever (septic arthritis, osteomyelitis, intracranial abscess, tooth abscess, mastoiditis)
  • History of cancer (new cancer; recurrence; metastases)
  • HIV/AIDS/injection drug abuse (infection; immunosuppression)
  • Facial asymmetry; deformity; mass; nodule; swelling of TMJ, mandible, parotid gland (trauma; cancer; infection, inflammatory arthropathy, lymphadenopathy, growth disturbance)
  • Neck mass/persistent cervical lymphadenopathy (cancer; infection)
  • Skin lesions; growing, pigmented - e.g. face, mouth, neck (cancer)

NICE Clinical Knowledge Summaries (CKS).  Temporomandibular disorders (TMDs). 2021 

Editorial Information

Last reviewed: 30/04/2024

Next review date: 30/04/2025

Reviewer name(s): Louise Ross , Alison Baird , Karen Glass .