Non-odontogenic Toothache Flashcards
What challenges are commonly encountered when diagnosing dental pain?
Pain in tooth may be referred from other orofacial structures or another tooth
3% of toothaches are nonodontogenic and 9% are mixed.
Why is it important to diagnose toothache correctly before treatment?
44% of non-odontogenic toothaches had been extracted prior to referral
How does site of pain relate to source of pain?
Sometimes the site of pain is not the same as the source of the pain.
In primary pain site = source
In heterotropic pain the site is not the same as the source. Pain is either projected or referred pain.
SOURCE OF PAIN SHOULD BE TREATED NOT SITE.
What are the differential diagnoses of nonodontogenic toothache?
Myofascial pain
Neurovascular pain
Cardiac pain
Neuropathic pain
Sinus pain
Somatoform pain
Pain of systemic origin
What causes myofascial toothache?
Hyperexcitable nodule at the motor endplate of skeletal muscle which refers pain to a distant site 80% of the time.
What is convergence theory?
Nerves converging on the trigeminal sensory nucleus refer pain to the same place making patient feel pain at tooth when it is from another site such as the anterior temporalis
How much of myofascial pain patients complain of toothache?
11% of myofascial pain patients complain of nonodontogenic pain
7% of cases of myofascial toothache had unnecessary endodontic treatment
How does myofascial pain typically present clinically?
Pain is non-pulsatile
Typically more constant ache than pulpal pain.
Pain is variable and intermittent over months or years and increases with emotional stress.
Not responsive to local provocation of the tooth
Pain increases with function of involved muscle.
LA does not affect the toothache
Where does the masseter muscle commonly refer pain to?
Pre auricular area and posterior maxillary and mandibular teeth
Where does the temporalis muscle commonly refer pain to?
Posterior maxillary teeth
Where does the sternocleidomastoid muscle commonly refer pain to?
Behind the ear, the eyebrow area, the maxillary and mandibular teeth
What headaches can present in orofacial region mimicking a toothache?
Migraine
Trigeminal autonomic cephalgias
What are the clinical characteristics of migraines?
Typically unilateral, moderate to severe pain of pulsatile quality
Pain lasts between 4 and 72 hours
Routine physical activities may aggravate the pain
Often accompanied by nausea, vomiting, phonophobia and/or photophobia
May present with or without auras
Aura develops between 5 - 20 minutes and subsides within 60 minutes and is immediately followed by headache
What are the types of auras in migraines?
VIsual auras: Scotoma (black dot in middle of visual field) Fortification spectra (Colours appearing in visual field)
What is a mid-face migraine?
Migraine may present in midface without involvement of the opthalmic division
What are the clinical signs of neurovascular orofacial pain?
Severe unilateral oral/perioral pain and may be referred to orbital and temporal areas
Tooth has throbbing pain and may wake the patient
Tooth may be hypersensitive to cold testing
Episodic attacks lasting 60 mins to >24 hours
Pain may become chronic
May be accompanied by ipsilateral lacrimation and/or conjunctival injections, ipsilateral rhinorrhoea and/or nasal congestion, ipsilateral cheek swelling.
Photo/phonophobia
Nausea
What is cardiac toothache?
Caused by cardiac ischaemia.
38% of patients with cardiac ischaemia report orofacial pain such as toothache (4%), mandible (45%), or the ear/TMJ
6% have pain solely in the orofacial region.
What causes referred pain in cardiac toothache?
Convergence and central sensitization of the trigeminal nerve complex
What are the clinical features of cardiac toothache?
Tight, burning quality
Associated with chest, neck, throat and shoulder pain.
Increases in intensity with physical exertion or exercise
Prior history of cardiovascular disease
Alleviated with nitroglycerin
Local provocation and local anaesthetic does not alter the pain
What is neuropathic pain and what are the most common causes?
Pain caused by lesion or disease of somatosensory nervous system and 2 types exist: Episodic such as trigeminal neuralgia and continuous such as painful traumatic trigeminal neuropathy
What is tic douloureux?
Brief electric shock like lancinating pains that affect the face unilaterally affecting one or more divisions of the trigeminal nerve
How does trigeminal neuralgia present clinically?
Trigger zone within the same division of the nerve provoked by touch, shaving, chewing, and talking
Paroxysms of sudden, intense, stabbing pain that last for a few seconds followed by refractory period
Remission period spontaneously occurs and lasts for weeks to years
Trigeminal neuralgia may return
What causes PRIMARY trigeminal neuralgia?
Most common cause is an aberrant vessel compressing the trigeminal nerve root where it enters the pons.
Superior cerebellar artery compresses V2 and V3
Anterior inferior cerebellar artery compresses V1
What causes SECONDARY trigeminal neuralgia?
Acoustic neuroma
Cholesteatomas
Osteomas
Basilar artery aneurysms
Angiomas
Plaques of multiple sclerosis (consider especially if bilateral trigeminal neuralgia)
What causes painful traumatic trigeminal neuropathy?
Crushing or cutting of a peripheral nerve (deafferentation)
May follow an injury such as external trauma, pulp extirpation, extraction or major oral surgery
Often mistaken as post-traumatic or postoperative complication
How does painful traumatic trigeminal neuropathy present clinically?
Stimulus dependent or spontaneous paroxysmal (stabbing/electric) pain affecting one or more trigeminal nerve divisions with background burning pain. Paroxysm lasting from seconds to minutes.
May note hyperalgesia, allodynia, swelling or flushing.
May note anaesthesia or hypoaesthesia
How common is sinus toothache?
15% of the population complains of chronic sinusitis
10% of maxillary sinusitis cases are odontogenic in origin
Nasal mucosa intimately in contact with roots of maxillary dentition often protruding into the sinus cavity.
What are the clinical symptoms of a sinus toothache?
Patient reports pressure or pain above or below the eyes, headache, hallitosis, fatigue, cough or ear pain
Toothache is increased with lowering of the head
Continuous dull ache of maxillary teeth that may be sensitive to percussion, mastication, and temperature.
Toothache is increased with applied pressure over the involved sinus
LA does not eliminate the pain
Diagnosis can be confirmed by air/fluid level on CT scan
What is a somatoform toothache?
A cognitive perception of pain that has no physical basis
Note that just because you can’t diagnose pain cause doesn’t mean that there isn’t a cause
What are the clinical symptoms of somatoform pain?
Pain descriptors are often diffuse, vague, and difficult to localize involving multiple teeth often.
Inconsistent with physiological pain and present without any identifiable pathological cause.
Patient presents with chronic pain behaviour
Accompanied often by psychotic features.
Lack of response to reasonable dental treatment
Unusual or unexpected response to therapy
What systemic conditions can potentially report nonodontogenic toothaches?
Diabetes
Sickle cell anaemia
MS
Menstruation
Chemotherapy-induced toxicity
Temporal arteritis
Neoplasms
These are based on case reports and case series
What warning symptoms should be considered when evaluating toothaches?
Spontaneous multiple toothaches
Inadequate local dental cause for the pain
Stimulating, burning, non-pulsatile toothaches
Persistent, recurrent toothaches
LA of offending tooth does not eliminate the pain
Failure of toothache to respond to reasonable dental therapy
