Case• 11. Pain on biting
A 32-year-old man presents at your general dental practice surgery with intermittent pain on biting. Identify the cause and discuss treatment options.
He complains of pain on biting which is unpredictable, extremely painful and sharp but poorly localized. It originates in the lower right quadrant and lasts a very short time, only as long as the teeth are in contact, and is so painful that he has become accustomed to eating on the left. The pain only arises on biting hard foods or deliberately clenching his teeth. Apart from these sharp electric shock-like pains he has no other symptoms.
History of complaint
The pain is a recent phenomenon, having been first noticed a month or two ago. At first it was frequent but it has become less of a problem now that he has learnt to avoid triggering the pain. He has not noticed the pain being provoked by hot or cold.
The patient has been a regular attender at your practice since childhood. He has a small number of relatively small restorations. At his last appointment, some 4 months ago you placed an amalgam restoration in the lower right second molar.
▪ Based on what you know already what are the likely causes? Explain why.
A pulpal pain is the most likely cause because the pain appears to originate in a tooth and is poorly localized. Pain of periodontal ligament origin should be well localized. However, pulpitis appears not be present because there is no sensitivity to hot or cold. Pulpitis caused by placement of the recent amalgams and pain due to caries or exposed dentine can be excluded for the same reasons.
A crack in the tooth or electrogalvanic pain are possible causes suggested by pain on biting. Both are triggered by tooth–tooth contact.
Trigeminal neuralgia should be considered as an unlikely nondental cause. It causes paroxysmal stabbing or electric shock-like facial pain in distributions of the trigeminal nerve and may be initiated by touching or moving trigger zones. It usually affects the middle-aged or elderly. The history of pain on biting is almost conclusive of a dental cause but it can be difficult to exclude trigeminal neuralgia in some patients, particularly when trigger zones lie in the mouth or attacks are triggered by eating. If no dental cause is found, the possibility of trigeminal neuralgia may need further investigation.
Acute periodontitis caused by an occlusal high spot on the recently placed amalgam needs to be considered. However, although this could cause great tenderness on biting it would be expected that the pain from the bruised periodontium would be present at other times. Also, such periodontally-sensed pain would be well localized.
▪ What additional questions would you ask? Why?
The patient should be asked about clenching or bruxing of the teeth because the additional occlusal load can cause fracture and will determine treatment options.
The patient describes a habit of nocturnal bruxism with some tenderness of masticatory muscles at times of stress.
There is a suspicion of hypertrophy of the masseter muscles on clenching.
The incisal edges of the upper and lower anterior teeth are worn and the dentine is exposed. The cusps of the posterior teeth are slightly flattened or rounded consistent with mild attrition. There is no evidence of any loss of attachment or gingival recession.
The appearance of the teeth in the lower right quadrant is shown in Figure 11.1. The lower right molars and premolars contain small- to moderate-sized MOD amalgam restorations, those in the molars having small buccal extensions. The upper molars have small separate MO and DO amalgams, the DO amalgams having buccal extensions. The upper premolars are unrestored.
▪ What features of the restorations would you note particularly?