Toothache of Nonpulpal Origin

Nonodontogenic pain can be extremely distressing to the patient and baffling to the clinician. For patients, this can result in years of misdiagnosis, mismanagement, and overtreatment, thus risking the development of chronic pain pathology. To further complicate the problem, patients will jump from one provider to another as treatment failures continue to mount. A history of unsuccessful treatment by numerous providers is a red flag for the endodontist to expand the differential diagnosis to include pain of a nonodontogenic origin. In this group of patients taking the time to complete a comprehensive history will avoid unneeded diagnostic tests and misdirected treatment.

All pain disorders have a negative effect on the patient and those around them. This is especially true when it comes to painful conditions in the facial region. These disorders have an especially high level of concern because this region is the center for both verbal and nonverbal communication as well as nourishment.

The face is also highly innervated by both sensory and special sensory nerves. The motor and special motor nerves respond to this afferent information. This cross talk of malfunctioning nerves can make specific diagnosis elusive for the provider and at the same time making the patient frantic for an explanation.

This combination is the perfect environment for unnecessary or unsupported treatment resulting in more failure and despair. Using a linear model of cause and treatment is not always successful. To address this issue further, the research diagnostic criteria of Dworkin and Leveche considered the psychosocial side of pain and that both physical conditions and psychologic conditions contribute to the suffering, pain behavior, and disability associated with a person’s pain experience.

Dentists are often the first clinicians involved in diagnosis and treatment of these conditions. ^,

To be successful in treating these patients, it is important to have a clear understanding of the many different ways in which the patient may experience nonodontogenic pain and how to avoid unnecessary treatment. In the dental field, the most useful pain consultants are (1) orofacial pain trained dentists, (2) endodontists, and (3) oral maxillofacial surgeons. These professionals are a resource for medically trained pain management providers as well as dentists. Referral to one of these specialists is preferable to sending a patient to an urgent care facility or an emergency room.

Incidence of Orofacial Pain

The frequency of continuing pain after endodontic treatment has been reported at 5%. Of these patients, 62% were found to be a pain of nonodontogenic origin. The frequency of persistent pain after orthograde root canal treatment in one study subsequently identified as nonodontogenic pain was 53%. In this study myofascial pain was determined to be the source. Another study found that 44% of patients with persistent pain had previously received endodontic treatment or tooth extractions in an attempt to resolve their pain. Moreover, 23.5% of patients with headaches reported tooth pain referral as well. The importance of comprehensive examination of the muscles in the head and neck is emphasized in a study that reported pain referral patterns to the teeth in 138 of 230 patients.

In a survey of 827 randomly selected individuals from a general population group, 10% reported pain in the head, face, or neck. Another group surveyed 1016 members of an HMO and found that 12% reported facial pain within the preceding 6 months and 26% reported headache. Lipton et al. surveyed 45,711 households and found 22% had at least one of 5 types of orofacial pain in the preceding 6 months. Most common orofacial pains were toothache at 12.2%, temporomandibular (TM) joint pain at 5.3%, and face/cheek pain in 1.4%.

To better understand disorders of the orofacial region, a study was undertaken titled “Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA).” This study provided improved insight into the number of people affected by pain in the orofacial region. Epidemiologic surveys in the United States, Canada, and the United Kingdom report the frequency of orofacial pain in the general adult population as ranging from 14% to 40%.

Basic Terminology in the Understanding and Diagnosis of Pain

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. ^, Orofacial pain refers to oral pain, dental pain, and pain in the face above the neck, anterior to the ears, and below the orbitomeatal line.

Common Terms

• • Algesia – Any pain experience after a stimulus

  • Allodynia – Painful response to a nonpainful stimulus

  • Dysesthesia – An abnormal sensation that is unpleasant

  • Hyperalgesia – An increased pain response to a noxious stimulus

  • Hypoalgesia – A diminished pain response to a noxious stimulus

  • Hypoesthesia – A decreased sensitivity to stimulation similar to anesthesia

  • Neuroma – A mass of peripheral neurons formed by a healing damaged nerve

  • Neuropathic Pain – Aberrant sensation produced by a malfunctioning nerve

  • Nociception – Perception of pain arising from tissue damage or injury

  • Pain Threshold – The lowest level of stimulation perceived as painful

  • Pain Tolerance – The highest level of pain a subject is prepared (or able) to tolerate

  • Sensitization – The increased excitability of nerve terminals or neurons produced by trauma or inflammation of peripheral tissues

Diagnostic Process for Nondental Orofacial Pain

Due to the complexity of orofacial pain, many authors suggest classification or grouping of functional systems as the most direct method to evaluate these orofacial pain problems. ^{, ,} Effective diagnosis and treatment of these disorders require a working knowledge of functional neuroanatomy, peripheral nervous system (PNS) and central nervous system (CNS) pathways, descending pain-modulating systems, and their related structures. CNS changes may underlie persistent pain. The patient’s emotional response to continuing pain is another factor that should be considered in the diagnostic process. To be an effective care provider, the clinician must have a solid understanding of the various categories in which persistent orofacial pain can be classified.

It is important to remember that directing and providing the most appropriate care may involve multiple clinicians. By taking a thorough medical history and carefully processing clinical characteristics, the clinician can begin to identify the unique characteristics of extracranial, intracranial, musculoskeletal, vascular, neurologic, and psychological symptoms. This assessment provides the most direct path to diagnosis, referral, or treatment. ^{, , ,}

When a thorough assessment is completed, the clinician can confidently reassure the patient that his or her symptom will be appropriately managed. This proficiency is another critically important skill for the specialist to develop. Without confidence in the treatment provider, the patient’s anxiety and worry can interfere with the diagnostic process and resulting care.

Localization of the Pain

• 1.

  Eyes, ears, nose, throat, sinuses, tongue, teeth, and glands are head and neck structures that may be a source of pain. The quality of pain in a region involving such a broad range of structures can range from mild aching to excruciating pain. As previously mentioned, the most common cause of pain in the orofacial region is dental pathology.

• 2.

  A diligent search for dental pathology should begin early and continue throughout diagnosis and treatment.

• 3.

  Pain of dental origin will often awaken a patient from sleep or prevent sleep. Patients may regard sleep disturbance as noncritical medical information. ^, Sleep disturbance is an important part of the differential diagnosis. It is important to ask very specific questions about the effect of pain on sleep patterns.

• 4.

  Pain of the pulpal tissues or periodontium is often very acute and easily localized on examination or by patient report. Affected teeth are typically painful to palpation or percussion. Use of percussion testing is extremely helpful in the diagnostic process.

• 5.

  Any tooth-related pain should be evaluated radiographically to exclude dental disease. Most computed tomography (CT) imaging and radiology reporting from a medical center do not provide an adequate evaluation of the dental structures. If imaging is completed, a dental provider should access the images and review them personally.

• 6.

  With nonodontogenic pain, the maxillary sinus and teeth are the areas that are most commonly affected by disease. Typical descriptors of sinus disease are “constant,” “aching,” “pressure,” and “fullness.” Pain will often include the teeth or ear. Fever, congestion, and/or discharge may also be present. Head position or movement can often exacerbate this symptomatology. ^,

Confusing Dental Pathology

Periodontal Ligament Pain

Caused by repetitive strain to the dental periodontal ligaments through clenching, gross occlusal prematurities, or trauma to the teeth, this type of pain is characterized by deep somatic musculoskeletal pain. Periodontal ligament pain is generally a dull, aching pain in and around the teeth and can affect multiple teeth. Inflammatory fluid accumulation from a periodontitis or an apical abscess may cause displacement of the tooth in its socket, with a resulting acute malocclusion and pain ( Fig. 5.1 ). The most common sign is tenderness of the teeth to percussion in the absence of pulpitis or periapical/periodontal abscess. Treatment consists of using a splint to protect the teeth, reducing oral habits, and encouraging healing. The use of a transitional splint can help in diagnosing and treating these conditions.

Periodontal ligament pain is cause by inflammatory and fluid accumulation from either a periodontitis or an apical abscess.

Redrawn after Fricton J, Kroening R, Hathaway K: TMJ and craniofacial pain: diagnosis and management , St. Louis, 1988, Medico Dental Media International, Inc.

Intracranial and Headache Pain

Although uncommon, neoplasm, hematoma, hemorrhage, edema, aneurysm, and infection of the CNS can result in facial pain. Space-occupying lesions are often associated with progressive pain complaints and associated neurologic deficit or signs. Patient descriptors, including the “worst” or “first,” have been identified as specifically pathognomonic of more serious conditions. ^{, , ,} These conditions can progress quickly and lead to permanent disability or even death. Prompt identification and referral for neurology consultation can be critical to successful diagnosis. The SNOOP acronym can be helpful to determine level of concern, as follows:

• • S ystemic symptoms or disease: fever, weight loss, human immunodeficiency virus (HIV), systemic cancer

  • N eurologic signs or symptoms: confusion, clumsiness, weakness, aphasia, vision change

  • O nset sudden: thunderclap, progressive, positional

  • O nset after age 40 years: vascular (temporal arteritis), tumor, infection

  • P attern change: any new or changed headache pattern or quality or increase in frequency or intensity

Some of the most difficult primary headache diagnoses involve the orofacial region. It is important to remember that headache disorders can and do occur anywhere in the trigeminal distribution and can be difficult to differentiate from disease. For example, midface migraine and sinus disease can look and act very similar in many ways to dental pathology. Careful history-taking is critical to diagnostic accuracy and treatment effectiveness. Recurrence and duration can often be helpful in differentiation of primary headache. In addition, with the introduction of the specific drug class triptans, a medication trial can help clarify the diagnosis.

Temporomandibular Disorders

Musculoskeletal conditions are the major cause of nonodontogenic pain in the orofacial region. Included in this group are cervical spine and temporomandibular joint disorders (TMD). Oral and facial pain may be the result of TMD, myofascial disorders, or systemic rheumatologic, collagen, or cervical spine disease. TMD refers to pain and dysfunction specific to the TM joint that frequently involves mandibular movement disorders. Palpation of the region is usually associated with exacerbations of pain, and functional pain is common.

The TM joint is made up of three major structures: the condyle, the disk, and the skull. The TM joint is a complex joint, capable of both rotational and translational movements. Rapid displacement of the joint can result in pressures that disrupt the disk–condyle relationship, resulting in lack of coordinated movement. On examination, this disorder can be identified as clicking or popping in the joint. Less subtle noises, such as crepitation, can occur with degenerative disease of the region and must be considered in the diagnostic process.

Mechanical disturbance of this joint is often associated with inflammatory events that often respond to antiinflammatory treatment. ^{, ,} Noise in the TM joint that presents without pain, catching, locking, or sudden and notable change in bite position is often simply a finding that requires no more than identification. Because of the TM joint’s location in relation to the ear, patients’ concerns about joint noise must be addressed and explained as present and being considered in the diagnostic process to avoid unnecessary treatment focused on the TM joint.

Trauma is thought to be the main cause of dysfunction in the region. Microtrauma resulting from tooth grinding or jaw clenching, or macrotrauma resulting from external forces such as a MVA or facial effect has been discussed in the literature as the etiology of such disorders. ^{, ,} Jaw joint and muscle strain and sprain (JAMSS) is another potential precedent to TMD and facial pain. Trauma may occur during dental treatment. Hyperextension of the mouth for extended time periods and excessive force placed on the jaw during a procedure or after local anesthetic injections may cause injury. More than 50% of patients with TMD associate initial onset of this problem with this type of trauma.

Psychological Disturbances

Psychological disturbances have also been proposed as a cause of tooth pain. However, even though practitioners know factors such as stress, muscle tension, anxiety, and depression can contribute to an enhanced experience of pain, psychological factors have not been established as a cause of toothaches of nondental origin. Psychological disturbances are considered more of a contributing factor to periodontal ligament strain and muscle pain but not tooth pain. Psychological illness with reported pain complaints is common. Psychological illness requires the inclusionary criteria present for any other disease and should not be assumed. Once identified, treatment plans should be developed and presented as clearly and succinctly as those of the other pain etiologies discussed.

It is important to remember that many of the currently described pain disorders were, as recently as the 1990s, considered to be psychological illnesses. Therefore care should be exercised when allowing this diagnosis to be made by exclusion. ^, It is also important to remember that with extended time, multiple treatment failures, and constant pain, patients who present with depression, fear, and feelings of hopelessness and helplessness are actually showing signs of a “normal” response to a chronic condition.

Types of Pain

Musculoskeletal Pain

Myofascial pain is the most common muscle pain disorder of the orofacial region. Muscle splinting, muscle spasm, and myositis are the most common acute conditions and, based on duration, may precede myofascial pain in etiology. Factors associated with aggravation of muscle pain include prolonged muscle tension, poor posture, parafunction, trauma, sleep disturbance, viral infection, metabolic disturbance, and specific joint pathology. The most common examination finding associated with muscle problems involves pain with palpation, movement anomalies, and referred pain. Knowing the common referral patterns for the head and neck muscles will save hours of confounding findings and prevent failed treatments. The text by Travell and Simons is the best resource for information about this disorder.

Joint Disorders

Joint disorders have been identified as a major cause of nondental pain in the orofacial region and are considered to be a subclassification of musculoskeletal disorders.

Neurovascular Pain

Migraines, cluster headaches, and hemicrania continua are types of headaches that result from changes in the nerves and blood vessels of the head. In some cases, through referral patterns of the trigeminal nerve, these headaches can also be felt in the teeth, causing toothaches. The pain can be spontaneous, severe, and throbbing, and it can have periods of remission. Treatment is directed at the cause of the headache and often includes behavioral therapy and medications.

Neuropathic Pain

Neurologic or neuropathic pain is the result of abnormality in nociceptors. These receptors are activated by stimuli that threaten or damage the body’s integrity. They respond to mechanical, thermal, and chemical stimuli. Both peripheral and central locations and mechanisms may be involved.

Decreased inhibition and/or increased peripheral activity result in two basic types of pain: paroxysmal and continuous neuralgias. ^{, ,}

Paroxysmal neuralgias are described as intense, sharp, stabbing, electric-like pains, usually of unilateral presentation involving a specific nerve.

The intensity of the pain is described as “the worst pain known to man.” This type of pain can occur in short or extended-duration volleys. ^, Although the intensity of these types of pain is extreme, they do not often awaken the sleeping patient, which helps differentiate this pain from pulpal or periodontal pain.

Trigeminal neuralgia affects the fifth cranial nerve. It is usually unilateral and is more common in women over the age of 50. Etiology includes idiopathic, demyelination, or vascular malformations. ^, Additional etiology theory includes pathologic (bone) cavities at the site of previous tooth extraction, periodontal lesions, and previous endodontic therapy.

Because of the similarity between the symptoms of trigeminal neuralgia and dental etiology, it is common for patients to have consulted with an endodontist. The endodontic specialists must become very familiar with the unique features and provide the evaluation “to eliminate” toothache as the etiology.

The majority of patients describe the classic high-intensity, triggerable pain in association with such activities as eating and talking. Even simple things, such as a cold breeze, can trigger a pain episode. ^,

In addition to the paroxysmal nature of classic trigeminal neuralgia, a pretrigeminal neuralgia has also been described by Fromm. This type of pain is of note due to its more constant, dull aching characteristics and is often described by patients as feeling “like a toothache.” To further confound the pain provider, most neuralgias are disabled for 4 to 8 weeks by dental procedures such as endodontic treatment and oral surgery. When the pain returns, it is “transferred” to the next tooth in the same arch, which is then incorrectly treated. Patients can often undergo multiple endodontic procedures chasing this disorder.

Glossopharyngeal neuralgia and nervous intermedius neuralgia are more rare than trigeminal neuralgia and involve branches of the glossopharyngeal and vagus nerves. ^, Symptoms of pain often include the ear, throat, tonsillar pillar, and submandibular regions. Triggering mechanisms, including chewing, talking, and swallowing, are often the hallmark. Aggressive imaging of the region is recommended because of the high likelihood of regional lesion or pathology associated with this disorder.

Deafferentation Syndromes

Partial or total loss of nerve supply to a region can result in a painful condition. This disorder can be a direct result of traumatic injury, surgery, or a breakdown of the neural structures.

Deafferentation-type pain is thought to involve the sympathetic nervous system, as blockade of this system may often eliminate or reduce the complaints of the patient. Characteristic descriptors used with this type of pain seem most commonly to include the words “burning,” “stinging,” “itching,” and “crawling.” Pain is not always present immediately at the time of injury or trauma and may be the result of a breakdown of the central inhibition.

Atypical Odontalgia

This term is used to describe a persistent, painful condition in the oral cavity that cannot be readily attributed to a known cause. The International Headache Society defines atypical odontalgia (AO) as a subgroup of persistent idiopathic facial pain that does not have the characteristic cranial neuralgias and is not attributed to another disorder.”

Phantom tooth pain, atypical facial neuralgia, and idiopathic toothache are terms that are used synonymously with AO.

Differential diagnosis includes these four findings:

• •

  Duration longer than 4 months

• •

  Normal radiographic examination

• •

  No clinical observable cause

• •

  Description as a toothache or tooth site pain

Words often used to describe this pain are “diffuse,” “burning,” “stabbing,” or “throbbing.”

It is generally thought that AO is a subset of neuropathic pain, i.e., “pain arising as a direct consequence of any lesion or disease affecting the somatosensory system.” In this instance, it is thought to result from injury to sensory fibers supplying the extirpated pulp or extracted tooth.

Dental procedures, testing, and diagnostic block of the somatic system are rarely conclusive. Confirmation is associated with positive sympathetic nerve block. ^{, ,}

Neuromas and Neuritis

Neuromas are a growth or tumor of nerve tissue and are often associated with trauma or a direct section of nerve tissue. Stimulation of the region is consistent for diagnostic purposes; however, treatment can be elusive due to recurrence. Neuritis as a systemic inflammatory response is often associated with herpes zoster viral infection. Aggressive and early identification and treatment can often decrease or eliminate the constant sequelae of a zoster episode. ^,

Referred Pain

Cervical Spine Pain

Disruption in spine position, structure, and movement can often refer pain into the orofacial region. Careful assessment, history, and clinical examination, including the cervical spine, are paramount to correct identification of etiology and exclusion of referred pain phenomena. ^{, ,}

These disorders can generally be subdivided into muscles or those from the cervical spine. These structures commonly refer to the face and should not be overlooked in cases wherein a diagnostic question exists.

Pain Arising from Vascular Structures

Carotidynia and temporal arteritis are two such disorders that can present with pain in and around the teeth, jaws, and related structures. Palpation localized to their specific anatomic locations assist in the diagnostic process. ^{, , ,}

Cardiac Toothache

Heart problems such as angina pectoris or acute myocardial infarction refer pain to the shoulder, arm, and even to the jaw. We know that these conditions can refer pain to teeth as well. Sometimes cardiac toothache is associated with chest pain, but occasionally it is not. When a toothache has a cardiac origin, it usually increases with exercise and decreases with medication specifically prescribed for the heart (such as nitroglycerin tablets). Treatment is directed to the underlying heart problem usually after a dentist has evaluated the tooth.

Sinus/Nasal Toothache

Problems in the maxillary sinuses and/or paranasal mucosa can refer pain to the upper teeth. The pain is usually felt in several teeth as dull aching or throbbing. Sometimes it is associated with pressure under the eyes, and it can increase with lowering the head (which puts pressure over the sinuses), coughing, or sneezing. Tests performed on the teeth, such as cold, chewing, and percussion, can increase the pain from sinus origin. A history of an upper respiratory infection, nasal congestion, or sinus problem should lead to suspicion of a “sinus toothache.” Diagnostic tests such as visual nasal examination, sinus x-rays, or magnetic resonance imaging (MRI) will reveal this condition. Also, application of topical anesthesia to the offending area should eliminate the pain. Treatment with antihistamines, decongestants, and antibiotics will help ( Fig. 5.2 ).

Sinuses and Associated Structures.

Redrawn after Fricton J, Kroening R, Hathaway K: TMJ and craniofacial pain: diagnosis and management , St. Louis, 1988, Medico Dental Media International, Inc.

Neoplasias and Other Lesions in the Head

Some tumors, aneurysms, and other intracranial disorders can cause pain in the mouth or teeth. The tooth symptoms are generally accompanied by other nerves malfunctioning or by systemic symptoms, such as weight loss, fatigue, and so on. These accompanying symptoms suggest more than a localized tooth problem is occurring. Tumors can also appear in the areas near the nerves of the teeth, which may cause the teeth to be loose or displaced. Proper imaging of the face, jaw, and head is important to evaluate for these problems. Although possible, these problems are very rare, and treatment needs to be directed to the specific problem.

Salivary Gland Dysfunction

Patients with salivary gland dysfunction can experience dental pain through different mechanisms. Pain may occur through referred pain from the glands to the teeth. It may also occur through compromising the health of the teeth and supporting structures and by the absence of the protective saliva. In such cases, a comprehensive evaluation of the salivary glands is needed ( Fig. 5.3 ).

Salivary Glands.

Redrawn after Fricton J, Kroening R, Hathaway K: TMJ and craniofacial pain: diagnosis and management , St. Louis, 1988, Medico Dental Media International, Inc.

BOX 5.2

Study Questions

• 7.

  The mental foramen is typically situated between the first and second mandibular molars.

  • a.

    True

  • b.

    False

• 8.

  Nasopalatine duct cyst (NPDC) typically presents as heart-shaped radiolucency between the maxillary central incisors.

  • a.

    True

  • b.

    False

• 9.

  Am recapitulates the process of odontogenesis before epithelial/mesenchymal induction.

  • a.

    True

  • b.

    False

• 10.

  Which of the following is true regarding malignant myeloma (MM)?

  • a.

    It is a disease of childhood.

  • b.

    It is histologically characterized by eosinophils and histiocytes.

  • c.

    Serologically, patients demonstrate high immunoglobulin production.

• 11.

  The majority of jaw lymphomas are of the large B-cell type.

  • a.

    True

  • b.

    False

• 12.

  What is the most common radiographic presentation of sickle cell anemia (SCA) in the mandible?

  • a.

    Widened marrow spaces

  • b.

    Sunray pattern

  • c.

    Punched out radiolucencies

• 13.

  Which of the following does not typically present as a multilocular radiolucency?

  • a.

    Ameloblastoma (Am)

  • b.

    Odontogenic keratocyst (OKC)

  • c.

    Traumatic bone cyst

• 14.

  Which of the following entities proves to be devoid of any content upon surgical exploration?

  • a.

    Traumatic bone cyst (TBC)

  • b.

    Odontogenic keratocyst (OKC)

  • c.

    Surgical ciliated cyst

• 15.

  Of the following entities, which has a well-known familial transmission?

  • a.

    Ameloblastoma (Am)

  • b.

    Ameloblastic fibroma (Amf)

  • c.

    Squamous odontogenic tumor (SOT)

• 16.

  All of the following are true regarding the radiographic features of Langerhan cell histiocytosis except one. Which is the exception?

  • a.

    Often presents with teeth hanging in air pattern

  • b.

    Often presents with punched-out radiolucencies

  • c.

    Often present as multiple radiopaque jaw masses

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