There are three main categories of conditions that can lead to a patient perceiving and reporting pain as coming from the tooth but are not related to caries, pulpitis, or periradicular pathology. First, chronic conditions (musculoskeletal primarily) can create nociceptive (i.e., pain impulses) pain signals that include referred pain to teeth. Second, neuropathic conditions which are nonnociceptive (pain signals are generated by the neural pathways themselves and not as result of tissue injury) can create perceived pain that can “shoot” or “stab” in an area that can include teeth, gingiva, and other oral structures. Third, there are less understood conditions that are associated with a tooth or teeth and are “nonodontogenic” in nature. The pain is perceived and centered in the tooth, but there is no detectable pulpal or periradicular pathology.

Chronic pain conditions are more likely to be associated with multiple concurrent (comorbid) diagnoses and referred pain than acute conditions. Acute conditions in one tooth may refer pain to other teeth in the posterior regions of the dentition. Diagnostic confusion from this type of pain referral is apt to be short lived since acute inflammatory conditions are usually self-limiting, will usually reveal the actual source of the pain in a few days, and will resolve upon treatment (Bender 2000). Chronic pain referral presents a more different dilemma because of the architecture of the central nervous system (CNS). Long-term pain has been shown to create changes in the CNS through an increasing ability for pain transmission to occur (plasticity) and central sensitization (sensitization of the central nervous system) which results in a significantly lowered pain thresholds and a widening of field of reported pain (Woolf 2011; Fernandez-de-las-Peñas et al. 2009). Convergence occurs from a decreasing number of neurons moving from peripheral to central. The cervical and trigeminal systems have been shown to converge into the same region of the brainstem (spinal trigeminal nucleus) creating decreasing thresholds, upregulation of pain, and pain referral (Ge et al. 2004). As an example, a cervical muscle such as the trapezius can influence pain and referral in the anterior temporalis muscle on the face. It is very understandable that this could impact patient perception. The result is that chronic pain conditions can result in consistent pain referred from a distant site to the dentition. One study reported demonstrated an 85 % incidence of pain referral for chronic orofacial pain patient during the examination. Of the same group, 11 % reported pain referred to their teeth (Wright 2000). Pain chronicity and central sensitization have significant implications for the differential diagnosis of a reported toothache.

The presentation of chronic pain and acute pain differ greatly. Therefore, the management is also very different. Acute pain is primarily monofactorial, associated with inflammation which occurs following injury, usually has a short duration, and resolves with the healing of the insult. Chronic pain is multifactorial (often presents with several diagnoses), usually not associated with inflammation, displays a long duration, and continues often after resolution of the initial injury. Acute pain occurs in the periphery, and pain is transmitted via nociceptors (pain receptors) through the afferent neurons to the brain. Chronic pain is associated with the central sensitization as described in the previous paragraph in the CNS. Treatment for acute pain is associated with supportive therapy to promote healing and, if necessary, nonsteroidal anti-inflammatories for pain relief. Chronic pain requires a management strategy that addresses each of the known contributing factors or risk factors. Each diagnosis must be included. Patient-centered care is key including patient education, self-physical therapy and self-behavioral modification, and support for coping skills. Patients need to be educated about the importance of eight hours of sleep. Interuption of sleep has been shown to negatively impact anti-pain neuro transmitters and mood. Pharmacology utilizes psychotropic medications that help re-regulate and dampen the central sensitization of the trigeminal system such as tricyclic antidepressants (Books 1). Management strategies begin with reversible approaches and escalate only as necessary. A multidisciplinary approach with other providers including clinical psychology, physical medicine (physiatrists and physical therapists), and sometimes otolaryngology or neurology is often necessary (Fricton 2014).

Myofascial pain is a chronic musculoskeletal pain condition that involves the muscles and their attachments including the masticatory or cervical regions for our discussion. Palpation of the muscles reveals painful areas of hyper contracted tissue or “taut bands” which were called “trigger points” by Dr. Janet Travell (Book 2). The quality of the pain is often dull and achy which will vary in intensity often in the moderate to severe range from day to day. The duration is usually hours to days and may be continuous for months or years. The condition is bilateral, but one side often predominates in intensity. Other chronic conditions such as headaches, fibromyalgia, sleep disturbances, depression, otalgia, and bruxism are comorbid (Fricton 2007). The muscles of mastication likely refer pain to the dentition more than any other structures (Ehrmann 2002).

During muscle palpation, the patient will report a painful muscle that duplicates the pain of the chief concern including both the local discomfort and the referral pattern – without prompting from the examiner. This duplication means that the pain descriptors are very similar (familiar) to the chief concern and the pain occurs not only at the muscle site but also at the distant referral site (i.e., the tooth or other structure). Removal of the trigger point or source of pain leading to the referral will also eliminate the pain at the distant site. Diagnostic anesthesia such as 3 % mepivacaine can be utilized to anesthetize the suspected trigger point.

The superficial masseter, the most commonly implicated muscle, may refer pain to the ipsilateral maxillary or mandibular posterior teeth (Handa et al. 2013). Different aspects of the muscle refer to different distant sites. The superior section refers to the maxillary teeth, and the insertion or more inferior section refers pain more often to the mandibular teeth. The temporalis muscle may refer pain to the ipsilateral maxillary teeth (Wright 2000). The most anterior segment reported will refer to the anterior teeth, the middle section to the premolar teeth, and the more posterior segment to the molars. The anterior digastric muscle may refer pain to the mandibular incisors.

A panoramic survey would be utilized to rule out any gross pathology, and additional imaging would be appropriate to evaluate dental pathology.

This condition is usually a chronic long-term musculoskeletal condition that requires a multidisciplinary approach. The management plan needs to include the following (Fricton 2014; Romero-Reyes and Uyanik 2014):