Temple and eye pain that changed together with jaw-related symptoms

This de-identified case involved pain below the left cheekbone, below the ear, in the cheek, and on opening, with later changes in temple and eye discomfort. These locations have many possible causes and this course cannot be generalized.

Overview of the 2019 course

The implant restoration and surrounding tissues, digital dynamic occlusion with T-Scan, jaw movement, and masticatory muscles were assessed together.

Care included one botulinum-toxin injection and five trigger-point injections over six visits. Pain was reduced by more than half at the sixth visit, and a later telephone check recorded no pain.

Because several interventions and natural symptom variation were involved, improvement cannot be attributed to botulinum toxin alone.

Can temple and eye pain change together?

The temporalis muscle moves the jaw, and pain from the TMJ or masticatory muscles can sometimes be perceived at the temple or around the eye as referred pain.

If pressing the temple changes familiar eye discomfort or examination reproduces familiar symptoms with jaw movement or temporalis palpation, a functional relationship can be explored.

This response does not prove that the eye pain started in the temporalis or TMJ. Eye disease, migraine, and neurologic causes need appropriate assessment first.

Initial cheek and below-ear pain

In 2019, the patient reported roughly one year of left-cheek and below-ear pain that had begun around the period of an implant restoration. Eating did not hurt, but opening the mouth did.

Pain below the cheekbone, below the ear, and in the cheek can arise from teeth and restorations, salivary glands, ears, soft tissue, nerves, the TMJ, or masticatory muscles. Location alone cannot identify the source.

Did the implant restoration cause the pain?

A similar timeline is an important clue but is not proof of causality. The implant, neighboring teeth and gums, restoration, jaw joints, and muscles were evaluated separately.

T-Scan was used to review the sequence and balance of dynamic tooth contacts. A relatively low contact height on the implant side and the current left-right balance were considered, without assuming that adjustment or replacement was automatically required.

If symptoms recurred, the need for restoration revision would be reconsidered using reproducible findings rather than timing alone.

Why can opening hurt when eating does not?

Opening and chewing load the joint and muscles in different ranges and patterns. Assessment includes comfortable and maximum opening, where pain begins, deviation, sound or catching, and whether palpation reproduces familiar pain.

How was a feeling of difficulty speaking approached?

‘Difficulty speaking’ can mean trouble finding words, slurred articulation, altered voice, throat catching, or fatigue around the jaw and neck. These meanings need to be separated.

Sudden slurred speech, inability to produce or understand words, facial weakness or numbness, or limb weakness requires immediate emergency assessment rather than a TMJ explanation.

Persistent or worsening speech, swallowing, breathing, or voice symptoms require neurologic, ENT, or other appropriate medical assessment. One normal MRI does not exclude every neurologic or speech disorder and does not prove a TMJ cause.

Only after appropriate medical assessment is unrevealing may the relationship between prolonged speaking load and jaw, cheek, submandibular, tongue, or neck muscle function be explored.

Relevant clues include worsening after prolonged or rapid speech, improvement with rest or slower speech, concurrent jaw or cheek fatigue, reduced opening, deviation, catching, and reproduction with muscle examination.

The original record only stated that speaking felt difficult; it did not provide neurologic or MRI results. Therefore this case itself does not classify that symptom as TMJ-related.

Past eye pain after an uncertain lifting procedure

The patient recalled pain above the right eye after a facial procedure three or four years earlier, remembered as a lifting treatment. The exact procedure was unclear, so no causal link to later eye or jaw pain was assigned.

Sudden vision loss, double vision, severe redness, pain with eye movement, or neurologic symptoms requires ophthalmic or appropriate medical care first.

Limits of the radiograph

Radiographs help assess joint bone and position but cannot alone explain cheekbone, below-ear, cheek, or eye pain. Muscles, ligaments, and other soft tissues may not be adequately represented.

Changes across visits

Second visit

The patient reported substantial improvement, and pressing the left cheek no longer produced the earlier pain. No marked hard muscular band was felt on clinical palpation.

Rapid improvement after one visit was not equated with complete recovery. Residual symptoms and recurrence were still followed.

Third visit

The patient then described pain extending behind the ear and discomfort at the temple and around the eye. These changing locations were recorded separately rather than assumed to have one source.

Fourth visit

Eye pain had resolved, temple discomfort remained slightly, and eating pain was much better. Pressing the temple seemed to release the area and reduce eye discomfort.

Because the temporalis is a masticatory muscle, this observation was worth assessing, but symptom relief with pressure did not prove causation.

Fifth visit

After about ten pain-free days, temple pain returned. Its location and timing differed from the initial cheek and below-ear pain, so the recurrence was documented separately.

Recurrence did not automatically mean treatment failure or the same cause. Jaw use, clenching, sleep, lifestyle, and other headache causes remained relevant.

Sixth visit and telephone follow-up

At the sixth visit, pain was reduced by more than half and only stiffness remained. The patient later reported by telephone that there was no pain and felt another visit was unnecessary, so the 2019 course ended.

What injections were used in 2019?

The six-visit course included one masseter-area botulinum-toxin treatment and five trigger-point injections. The combination and frequency apply only to this patient.

A previous adverse experience with glabellar botulinum toxin

The patient reported discomfort or an adverse reaction after a prior cosmetic glabellar injection and recalled being told that botulinum toxin might not suit him.

Before retreatment, the exact symptoms, timing, duration, and product should be reviewed. A local discomfort is different from suspected allergy, swallowing or breathing difficulty, or generalized weakness.

A previous adverse experience is not automatically an absolute contraindication, because target muscle, indication, product, and dose may differ. Suspected serious reactions require medical evaluation before any repeat procedure.

After individualized review, the planned 2019 jaw injection was completed without the same reaction being documented. This one case does not guarantee safety or efficacy for another patient.

Does one poor response mean botulinum-toxin resistance?

No. Diagnosis, target muscle, injection site, dose, product, interval, assessment timing, and other pain causes should be reviewed before neutralizing-antibody resistance is suspected.

A 2023 meta-analysis across multiple indications found newly detected neutralizing antibodies in 27 of 5,876 evaluable patients, 0.5 percent, with 16 patients, 0.3 percent, remaining positive at study end.

A study of 503 patients with secondary nonresponse found that treatment failure and antibodies did not always coincide. These studies were not limited to TMD or masticatory pain.

Lack of effect and an adverse reaction must also be distinguished. Repeated loss of effect may warrant record review and specialist evaluation, while allergy, dysphagia, breathing problems, or generalized weakness requires caution before retreatment.

Preventive injections in 2020 and 2021

After the 2019 pain course, this patient received separate preventive jaw injections in 2020 and 2021 while reporting no jaw pain.

Selected patients with recurrent masticatory-muscle pain or overactivity and a favorable prior response may be reassessed for prevention, but evidence is insufficient to recommend routine annual injections for all pain-free patients.

Current muscle state, clenching, chewing function, prior benefit, and adverse events should be reviewed each time rather than repeating a fixed schedule automatically.

How the research was used

The cited studies address temporalis referred pain, common referral areas in TMD, statistical links with eye and ear symptoms, botulinum toxin for persistent myofascial pain, speech-related jaw movement, and neutralizing antibodies.

These studies provide context. They do not prove that the implant caused pain, that eye symptoms originated in the jaw, or that another patient should receive the same injection combination or preventive schedule.

Frequently asked questions

Does pain beginning after an implant restoration prove the restoration caused it?

No. Timing is a clue, but the restoration, teeth, gums, dynamic bite, jaw movement, and muscles need to be evaluated together.

Can opening hurt while eating does not?

Yes. Opening and chewing use different ranges and loads. Pain onset, movement path, sounds, catching, and muscle findings help guide evaluation.

Does a normal MRI make speech difficulty a TMJ symptom?

No. One normal MRI neither excludes every neurologic cause nor proves a jaw cause. Sudden or progressive speech and neurologic symptoms need medical evaluation.

Does one ineffective injection prove resistance?

No. Neutralizing-antibody resistance is possible but uncommon, and diagnosis, target, dose, timing, and other causes need review first.