Non-odontogenic Toothache

Question 1

What challenges are commonly encountered when diagnosing dental pain?

Answer 1

Pain in tooth may be referred from other orofacial structures or another tooth

3% of toothaches are nonodontogenic and 9% are mixed.

Question 2

Why is it important to diagnose toothache correctly before treatment?

Answer 2

44% of non-odontogenic toothaches had been extracted prior to referral

Question 3

How does site of pain relate to source of pain?

Answer 3

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.

Question 4

What are the differential diagnoses of nonodontogenic toothache?

Answer 4

Myofascial pain

Neurovascular pain

Cardiac pain

Neuropathic pain

Sinus pain

Somatoform pain

Pain of systemic origin

Question 5

What causes myofascial toothache?

Answer 5

Hyperexcitable nodule at the motor endplate of skeletal muscle which refers pain to a distant site 80% of the time.

Question 6

What is convergence theory?

Answer 6

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

Question 7

How much of myofascial pain patients complain of toothache?

Answer 7

11% of myofascial pain patients complain of nonodontogenic pain

7% of cases of myofascial toothache had unnecessary endodontic treatment

Question 8

How does myofascial pain typically present clinically?

Answer 8

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

Question 9

Where does the masseter muscle commonly refer pain to?

Answer 9

Pre auricular area and posterior maxillary and mandibular teeth

Question 10

Where does the temporalis muscle commonly refer pain to?

Answer 10

Posterior maxillary teeth

Question 11

Where does the sternocleidomastoid muscle commonly refer pain to?

Answer 11

Behind the ear, the eyebrow area, the maxillary and mandibular teeth

Question 12

What headaches can present in orofacial region mimicking a toothache?

Answer 12

Migraine

Trigeminal autonomic cephalgias

Question 13

What are the clinical characteristics of migraines?

Answer 13

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

Question 14

What are the types of auras in migraines?

Answer 14

VIsual auras: Scotoma (black dot in middle of visual field) Fortification spectra (Colours appearing in visual field)

Question 15

What is a mid-face migraine?

Answer 15

Migraine may present in midface without involvement of the opthalmic division

Question 16

What are the clinical signs of neurovascular orofacial pain?

Answer 16

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

Question 17

What is cardiac toothache?

Answer 17

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.

Question 18

What causes referred pain in cardiac toothache?

Answer 18

Convergence and central sensitization of the trigeminal nerve complex

Question 19

What are the clinical features of cardiac toothache?

Answer 19

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

Question 20

What is neuropathic pain and what are the most common causes?

Answer 20

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

Question 21

What is tic douloureux?

Answer 21

Brief electric shock like lancinating pains that affect the face unilaterally affecting one or more divisions of the trigeminal nerve

Question 22

How does trigeminal neuralgia present clinically?

Answer 22

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

Question 23

What causes PRIMARY trigeminal neuralgia?

Answer 23

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

Question 24

What causes SECONDARY trigeminal neuralgia?

Answer 24

Acoustic neuroma

Cholesteatomas

Osteomas

Basilar artery aneurysms

Angiomas

Plaques of multiple sclerosis (consider especially if bilateral trigeminal neuralgia)

Question 25

What causes painful traumatic trigeminal neuropathy?

Answer 25

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

Question 26

How does painful traumatic trigeminal neuropathy present clinically?

Answer 26

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

Question 27

How common is sinus toothache?

Answer 27

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.

Question 28

What are the clinical symptoms of a sinus toothache?

Answer 28

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

Question 29

What is a somatoform toothache?

Answer 29

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

Question 30

What are the clinical symptoms of somatoform pain?

Answer 30

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

Question 31

What systemic conditions can potentially report nonodontogenic toothaches?

Answer 31

Diabetes

Sickle cell anaemia

MS

Menstruation

Chemotherapy-induced toxicity

Temporal arteritis

Neoplasms

These are based on case reports and case series

Question 32

What warning symptoms should be considered when evaluating toothaches?

Answer 32

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