Endodontic Pain or TMD? Differential Diagnosis Gary D. Klasser Orofacial Pain
“You must understand function before you can understand dysfunction” Dr. W. Bell “A clinician can not treat a disorder until he or she has a sound understanding of order” “You can not diagnose what you do not understand” Unknown
Introduction Toothache - most common complaint 12.2% of the general population report a toothache within the last 6 months (Lipton, Ship and Larach-Robinson) Diagnosis can be challenging and complicated Pain from one tooth may be referred from another tooth or from other orofacial structures Other facial pain disorders may mimic the symptoms of toothache Proper Diagnosis is critical
Clinical Characteristics of Odontogenic Pain Mainly inflammatory 2 Tissues: Pulp and Periodontium Functionally and embryologically distinct Pain is perceived differently Teeth are visceral tissues that function as part of the musculoskeletal system Pulpal pain = visceral pain Periodontal pain = musculoskeletal pain
Pulpal Pain Types: Reversible or Irreversible Reversible: brief, non-spontaneous, provoked pain that is present only as long as a stimulus is in contact with the tooth Irreversible: prolonged pain provoked by a stimulus or occurring spontaneously If pain is prolonged and intense, central excitatory effects may produce pain referral
Pulpal Pain Deep, dull, aching pain of a threshold nature Often difficult to localize Occurs irrelevant to biomechanical (masticatory) functions
Common Characteristics of Pulpal Pain 1. Quality of pain is dull, aching, throbbing and occasionally sharp 2. An identifiable condition that reasonably explains the symptoms 3. Response to local noxious stimulation is proportionate and predictable 4. Pulpal pain tends to get better or worse, but rarely stays the same over time 5. Local anesthesia of the suspected tooth eliminates the pain
Odontogenic pain can be extremely versatile and have the propensity to mimic many other pain disorders Rule of Thumb Consider all pains in the mouth and face to be of dental origin until proved otherwise.
Periodontal Pain Deep somatic pain of the musculoskeletal type (Okeson) It is related to the biomechanical (masticatory) function It responds to provocation proportionately and in graduated increments Precise localization of the stimulus therefore the offending tooth is readily identifiable
Common Characteristics of Periodontal Pain 1. Pain is dull and aching 2. An identifiable periodontal condition explains the symptoms 3. Response to local mechanical pressure is proportionate to the amount of force applied, rather than a threshold response (as in pulp) 4. During chewing, the tooth feels sore or elongated. Discomfort is often felt when biting pressure is released rather than while it is sustained***(GARY, see notes section of this slide) 5. Local anesthesia of the suspected periodontal tissue eliminates the pain *** Gary, this description can be easily confused with symptoms of cracked tooth syndrome (CTS). CTS also produces a sharp discomfort upon release with lingering dull ache. This can either be from a weak cusp or from M-D or Bu-Ling fracture. That needs to be explained.
Site of Pain vs. Source of Pain The location where the patient feels the pain Easily located by asking the patient to point out the region of the body that is painful Source of Pain That area of the body from which the pain actually originates
Site (where it hurts) = Source (where it originates) Primary Pain Site (where it hurts) = Source (where it originates) Eg./ cut finger Heterotopic Pain Site ≠ Source Eg./ cardiac pain
Rule of Thumb Successful therapy is achieved by treating the Source of pain, not the Site of pain
Non-Odontogenic Toothache TYPES Myofascial toothache 2. Neurovascular toothache 3. Cardiac toothache 4. Neuropathic toothache Episodic Continuous 5. Sinus toothache 6. Psychogenic toothache
Myofascial Toothache Pain is non-pulsatile Typically more of a constant ache than pulpal pain Variable , intermittent over months or years Pain tends to increase with emotional stress Not responsive to local provocation of the tooth Pain increases with function of involved muscle (Trigger points) Local anesthetic of the tooth does not affect the toothache Local anesthetic of the involved muscle (trigger point) reduces the toothache
Neurovascular Toothache Pain is spontaneous, variable and pulsatile; simulates pulpal pain Has periods of remission. Episodes of pain may pose a temporal behavior appearing at similar times during the day, week or month Lack of reasonable dental cause of pain Effect of local anesthesia is unpredictable May follow illness, sinusitis, dental treatment, surgery or trauma, appearing to be a complication of a former experience Very frequently initially felt in a tooth (maxillary canine and premolar usually) as a toothache so convincingly that dental treatment may be undertaken , even when only minor dental cause can be located
May undergo remission following dental treatment, but recurrence is a characteristic of neurovascular pains. May spread to adjacent teeth, opposing teeth or the entire face If the pain experience is protracted, it may induce autonomic symptoms With time, the complaint spreads to involve wider areas of the face, neck or shoulder and may evoke muscle pain and restricted movement Pain may respond to ipsilateral carotid pressure or migraine medications
Cardiac Toothache Presence of aching pain that is cyclic Toothache is increased with physical exertion or exercise Toothache is associated with chest pains Toothache is decreased with nitroglycerin tablets Local provocation of the tooth does not alter the pain Local anesthetic does not arrest the toothache
Neuropathic Toothache: Episodic 1. Unilateral, sudden, sharp, severe, lacerating and shock-like (paroxysmal) 2. Provoked by relatively innocuous peripheral stimulation of a “trigger zone” or may occur spontaneously 3. Local anesthetic at the tooth will not reduce the pain unless it also represents the “trigger zone” (very rare) 4. Local anesthetic at the “trigger zone” will reduce the attacks 5. Patient is typically asymptomatic between the episodes
Neuropathic Toothache: Continuous Persistent, ongoing and unremitting May be increased by local provocation such as touching the tooth and surrounding gingiva, which adds confusion to the diagnosis Presence of other neurologic complaints such as hyperesthesia, hypoesthesia, anesthesia, paresthesia, muscular tics, weakness and paralysis as well as autonomic and special sense aberrations, depending on the fiber content at the site of neuropathy
Neuropathic Toothache: Continuous Types of neuropathic conditions Neuritis Deafferentation Sympathetically maintained pains
Neuropathic Toothache: Continuous 1. Neuritis Inflammatory condition in the peripheral distribution of the nerve due to trauma, chemical, viral or bacterial causes Arises in the maxillary or mandibular division of the trigeminal nerve along with other neurological symptoms Neuritis of the superior dental plexus due to extension from maxillary sinusitis may cause a toothache in and around one or more of the maxillary teeth Neuritis of the inferior alveolar nerve in the mandibular teeth from direct trauma, dental infection or surgery
Neuropathic Toothache: Continuous 2. Deafferentation Crushing or cutting of a peripheral nerve (Traumatic Neuralgia) May follow an injury such as external trauma, pulp extirpation, extraction or major oral surgery Often mistaken for a post-traumatic or postoperative complication
2. Deafferentation (Cont’d) Neuropathic Toothache: Continuous 2. Deafferentation (Cont’d) Atypical Odontalgia (Phantom Toothache) – Graff-Radford et al Pain is felt in a tooth or tooth site (maxillary canine and premolar are most common) Pain is continuous or almost continuous Pain persists more than four months No sign of local or referred pain Local anesthetic of the painful tooth provides equivocal results
3. Sympathetically Maintained Pains Deafferentation tooth pains may be influenced by the efferent activity of the sympathetic nervous system Normal sympathetic activity (sympathetic tone) can be responsible for maintaining the pain An increase in sympathetic activity could increase the pain condition Increased levels of emotional stress could aggravate this condition
Sinus Toothache Patient reports pressure or pain below the eyes *** See notes Toothache is increased with lowering of the head Toothache is increased with applied pressure over the involved sinus Local anesthetic of the tooth does not eliminate the pain Diagnosis can be confirmed by air/fluid level seen in appropriate imaging Pressure can also be felt above the eyes in the area of the Ethmoid Sinus. Toothache can also be induced by rapid side to side movement of the head. ( Sinus fluids tend to trail the head movement and lead to ache in posterior maxillary teeth – this happens to me when I get a bad sinus cold!) If one side is involved I often tell patients to sleep on the opposite side. Many times the sinus will drain to the opposite side while sleeping and produce similar symptoms in the opposite sinus. Differential Diagnosis can be assisted with use of local antihistamines ( sprays) or orally administered medications.
Psychogenic Toothache Patient reports that multiple teeth are often painful with frequent change in character and location A general departure from normal or physiologic patterns of pain Patient presents with chronic pain behavior Lack of response to reasonable dental treatment Unusual or unexpected response to therapy No other identifiable pain condition that can explain the toothache
Non-Odontogenic Toothaches Warning Symptoms- Summary 1. Spontaneous multiple toothaches 2. Inadequate local dental cause for the pain 3. Stimulating, burning, non-pulsatile toothaches 4. Constant, unremitting, non-variable toothaches 5. Persistent, recurrent toothaches 6. Local anesthetic blocking of the offending tooth does not eliminate the pain 7. Failure of the toothache to respond to reasonable dental therapy
Case 1 Chief Complaint: History: Lower left mandibular pain and toothache. History: 61 yr-old male with mild, continuous but variable, dull aching pain diffusely located in the left mandible and teeth. Mandibular movement did not increase the pain. The pain was preceded by left shoulder discomfort. The shoulder pain began 3 days ago. He went to his physician and was diagnosed as bursitis. NSAIDs were prescribed. Two days later, the left toothache pain began even though he had been edentulous for 20 years. He went to his dentist thinking that he had a problem with his lower denture.. His dentist took a periapical of the lower left area and discovered an impacted third molar. He was referred to the oral surgeon for extraction of the tooth.
Diagnosis??? Examination: Intraoral: A normal appearing edentulous mouth with satisfactory dentures. There is no palpable discomfort in the area of the impacted tooth. Radiograph revealed a complete bony impacted third molar in the left submandibular triangle without any pathology. Mandibular functions are normal. There is no dental, oral or masticatory cause for the complaint. TM joints: Normal. Muscles: Negative for any cause of pain. Cranial nerves: Within normal limits. Diagnostic Tests: Inferior alveolar nerve block in the left did not arrest the pain. Diagnosis???
Cardiac muscle pain referred as mandibular toothache
Case 2 Chief Complaint: Left mandibular toothache History: A 42 yr-old female with mild continuous protracted steady bright burning pain located in the left mandibular teeth and accompanied by paresthesia described as a sensation of “high teeth” and recently as “gingival swelling”. The complaint began 5 years ago following the surgical removal of an impacted left third molar. After a few months, dental pain began in the left mandibular first molar which was extracted and replaced by a fixed bridge that felt “too high” despite repeated occlusal adjustments and finally refabrication of the prosthesis. A year later, the left mandibular second molar was treated endodontically because of pain and later the left mandibular first and second premolars as well.
The bridge was replaced after the second premolar and second molar were extracted and replaced by a removable partial denture. She could not tolerate the prosthesis due to pain. Then some diffuse temporal discomfort began which lead to muscle therapy by first a Periodontist and then an Oral Surgeon unsuccessfully. Presently, she has an excellent prosthesis but she can not wear it because of pain and a sensation of gingival swelling. It feels no better when she leaves it out. Examination: Intraoral: The missing left mandibular teeth were replaced with an excellent removable partial denture which she does not wear. No dental cause is evident either clinically or radiographically. There is an acute tender spot to finger pressure located in the mucosal scar residual to the surgery for removal of the left mandibular third molar.
TM joints: Normal. Muscles: Minor tenderness in the left Temporalis. Local anesthetic of that muscle arrested only the muscle pain. Cervical: Normal. Cranial Nerves: Hyperalgesia, paresthesia and dysesthesia were noted at the gingival tissue over the former extraction sites. Diagnostic Tests: Local anesthetic into the mucosal scar provided immediate relief of pain and, therefore, it was presumed to represent a painful Neuroma. Excision, however, provided only a transitory relief and after a few weeks the pain returned as before. Diagnosis???
Continuous neuropathic pain (Deafferentation) caused by a previous nerve injury